YF005066 


1 


Memoirs  of  the  American  Academy  of  Arts  and  Sciences. 
Vol.  XIV,  No.  II.      May,  1918. 


WAVERLEY   RESEARCHES  IN  THE  PATHOLOGY 
OF  THE  FEEBLEMINDED. 

(Research  Series,  Cases  I  to  X.) 


WALTER  E.  FERNALD,  M.D.,  A.M. 
E.  E.  SOUTHARD,  M.D.   Sc.D. 
ANNIE  E.  TAFT,  M.I). 


Memoirs  of  the  American  Academy  of  Arts  and  Sciences. 
Vol.  XIV,  No.  II.    May,  1918. 


WAVERLEY  RESEARCHES   IN  THE   PATHOLOGY  OF   THE   FEEBLE- 
MINDED. 

(Research  Series,  Cases  I  to  X.) 


EDITED  BY 


WALTER  E.  FERNALD,  M.D.,  A.M.,  Superintendent  Massachusetts  School  for  the  Feeble- 
Minded,  Waverley,  City  of  Waltham, 

AND 

E.  E.  SOUTHARD,  M.D.,  Sc.D.,  Pathologist,  Massachusetts  Commission  on  Mental  Diseases, 
and  Bullard  Professor  of  Neuropathology,  Harvard  Medical  School, 

WITH  THE   COLLABORATION  OF 

ANNIE  E.  TAFT,  M.D.,  Special  Investigator,  Massachusetts  Commission  on  Mental  Diseases, 
and  Custodian  of  the  Neuropathological  Collection,  Department  of  Neuropathology,  Harvard 
Medical  School. 


I.    General  Aspects  op  the  Brain  Anatomy  in  the  Feeble-Minded,  with  partial  Bibliography  .        .        23 

E.  E.  Southard. 

II.    Clinical,  Anatomical,  and  Brief  Histological  Description  op  Ten  Cases  op  Feeble-Mindedness, 

with  84  plates  (Waverley  Research  Series,  Cases  I-X) 59 

E.  E.  Southard  and  Annee  E.  Taft. 

III.    Neuropathological    Correlations   with    Clinical   and    Psychometric    Findings    in    Feeble- 
mindedness (Waverley  Research  Series,  Cases  I-X) 109 

E.  E.  Southard  and  Annie  E.  Taft. 


PREFACE. 

We  present  herein  the  first-fruits  of  an  orienting  study  of  some  of  the  more  funda- 
mental problems  of  feeble-mindedness.  Rarely  has  the  problem  of  feeble-mindedness 
been  attacked  fundamentally  for  its  own  sake.  Yet  in  recent  years  and  in  the  immediate 
present  the  representatives  of  numerous  and  varied  interests  clamor  for  light  upon  what 
appear  the  limiting  problems  of  their  special  fields.  But  what  can  the  workers  in  feeble- 
mindedness as  such  and  for  its  own  sake  say  to 

a)  the  educators,  responsible  for  "laggards,"  truants,  "terrors,"  "exceptionals," 
"ungraded,"  specially  graded,  retarded,  and  backward  children; 

b)  the  court  authorities,  to  whom  the  educators'  problems  in  part  drift  and  figure 
as  psychopathic  cases,  defective  delinquents,  prostitutes,  and  the  like; 

c)  the  social  workers,  sometimes  over-ready  to  tar  all  these  cases  with  the  same  brush 
as  "mental"; 

d)  the  eugenists,  who  either  as  Galtonians  or  as  Mendelians,  often  tend  to  treat  as 
units  and  thought-counters  all  sorts  of  feeble-mindedness  and  perhaps  even  epilepsy 
under  a  single  caption; 

e)  the  generalizing  biologists,  with  their  counsel  of  perfection  in  the  guise  of  sterili- 
zation of  the  potential  parents  of  more  feeble-minded; 

f)  the  syphilographers  and  antialcoholists,  who  need  facts  for  their  propagandas 
and  at  any  rate  must  not  universalize  what  facts  are  obtainable; 

g)  the  legislators  and  alert  guardians  of  the  public  purse,  who  are  promised,  in  lieu 
of  impractical  sterilization,  a  program  of  segregation  —  What  can  the  workers  in  feeble- 
mindedness offer  to  all  these  inquirers? 

Satisfied  for  the  moment  with  an  astonishing  and  unfamiliar  publicity,  the  special 
workers  in  feeble-mindedness  shortly  turn  to  fundamentals.  Assured  in  our  own  minds 
that  not  all  school  "problems"  are  feeble-minded,  that  not  all  delinquents  are  defective, 
that  not  all  feeble-minded  are  institutional  subjects,  that  Pearson  and  Davenport  should 
not  lump  and  unify  so  medically  obvious  a  pot-pourri  as  feeble-mindedness,  that  sterili- 
zation is  a  program  whose  first  physiological  lines  have  not  been  laid  down,  that  syphilis 
and  alcohol  have  not  had  their  shares  demarcated  in  the  matter  of  feeble-mindedness, 


i%S63&38 


20  FERNALD  AND   SOUTHARD. 

and  that  legislators  rush  in  where  specialists  find  no  footway,  we  run  to  our  books.  Mier- 
zejewski,  Bourneville,  Hammarberg,  Wilmarth,  Tredgold,  Bolton,  these  and  others  have 
done  their  part,  perhaps  most  notably  Bourneville.  Even  Germany  has  little  to  offer 
in  the  fundamentals,  save  perhaps  the  suggestions  of  the  lamented  Alzheimer.  The 
great  foundations  have  neglected  feeble-mindedness  (there  is  grim  humor  in  the  fact  that 
their  proposals  will  often  come  to  naught  through  the  existence  of  these  very  feeble- 
minded whom  the  great  foundations  neglect!). 

Yet  it  is  not  merely  the  present-day  neglect  of  fundamentals  in  feeble-mindedness 
that  justifies  our  undertaking.  Other  sciences  have  advanced  in  the  meantime.  What 
would  not  the  modern  ideas  of  glandular  dysfunction  have  meant  to  Bourneville?  How 
Hammarberg  would  have  rejoiced  had  the  modern  work  of  the  cortex-topographers 
enabled  him  to  omit  a  large  part  of  his  monograph  and  rush  on  to  deeper  studies  in  feeble- 
mindedness?    How  Wilmarth  would  have  enjoyed  the  resources  of  a  modern  laboratory! 

These  considerations  have  been  set  forth  more  extensively,  though  still  too  briefly, 
in  Article  I.  Here  we  wish  to  say  that  we  are  minded  to  present  a  series  of  studies  of 
the  anatomy,  and  especially  of  the  brain  anatomy,  of  the  feeble-minded  (including  idiots, 
imbeciles,  and  a  variety  of  subnormals  under  that  general  term)  to  which  we  set  the 
provisional  terminus  of  fifty  cases.  Until  we  have  presented  at  least  fifty  cases  from  an 
identical  point  of  view,  we  feel  that  we  shall  hardly  be  warranted  in  drawing  conclusions. 
Still,  epicritical  remarks  will  be  in  order  with  each  group  of  ten  cases  presented.  We 
plan  to  present  perhaps  ten  cases  a  year.  The  great  foundations  aforesaid,  which  have 
so  neglected  the  topic,  might  of  course  speed  up  the  work  appreciably;  yet  it  must  be 
granted  that  every  case  of  feeble-mindedness  is  so  much  a  unique,  not  to  say  Argus-eyed, 
a  problem  that  speeding-up  by  funds  alone  is  hardly  a  practical  policy.  More  living 
brains  are  needed  to  work  out  the  problems  of  the  brains  of  feeble-minded,  whether  living 
or  dead  —  but  cadit  quaestio,  that  is  the  urgent  lack  of  mental  hygiene  as  a  whole. 

We  must  accord  due  credit  and  extend  our  thanks  to  the  various  clinical  and  post 
mortem  observers  who  have  rendered  the  work  possible,  especially  to  the  Waverley  School 
workers,  to  Dr.  Myrtelle  M.  Canavan  of  the  Pathological  Service  of  the  Massachusetts 
Commission  on  Mental  Diseases,  who  has  performed  most  of  the  recent  autopsies,  and  to 
Dr.  Annie  E.  Taft,  Custodian  of  the  Neuropathological  Collection,  Harvard  Medical 
School,  who  has  been  charged  with  much  of  the  brain  analysis.  We  should  not  omit 
to  call  attention  to  the  excellence  of  the  photographic  work  of  Mr.  Herbert  W.  Taylor, 
Of  great  importance  also  is  the  work  of  the  technicians,  among  whom  we  may  mention 
Miss  Ellen  R.  Scott  and  Miss  Mae  Cameron. 

Perhaps  the  most  interesting  endeavor  in  the  present  volume  is  the  attempt  to  match 


WAVERLEY  RESEARCHES.  21 

brain  complexity  with  mental  capacity.  To  say  nothing  of  the  mind-and-brain  problem 
(the  less  mind,  the  less  brain,  and  vice  versa,  where  "less"  is  taken  not  too  quantitatively), 
We  feel  that  the  whole  problem  of  "mental  tests,"  now  sub  judice,  needs  anatomical  sup- 
port and  anatomical  critique.  Various  authorities  glibly  discard  all  "tests" — mind 
cannot  be  measured,  that  is  an  a  priori  certainty!  Other  persons,  chiefly  of  the  bureau- 
cratizing  group,  would  let  fly  at  the  institutions  cases  "feeble-minded"  by  a  Binet-Simon 
fraction,  particularly  if  they  be  antisocial  and  affected  by  symptoms  never  considered  by 
Binet  and  Simon.  The  epicritical  remarks  of  the  present  volume,  provisional  in  char- 
acter, are  therefore  levelled  at  the  question  of  matching  testable  mind  with  measurable 
brain.  The  situation  appears  on  the  whole  rather  favorable.  On  the  basis  of  the  clinical 
and  anatomical  details  of  Article  II,  Article  III  goes  on  to  the  more  doubtful  matter  of 
evaluation.     The  skeptical  may  confine  their  attentions  to  Articles  I  and  II. 

A  second  volume,  dealing  with  Cases  XI  to  XX  (including  also  "Mongolians"), 
is  within  hail.  Therein  we  hope  to  deal  still  further  with  the  major  problems  herein 
touched,  such  as 

a)  the  correlation  of  mental  and  cerebral  measurements. 

b)  the  theoretically  preventable  group,  (e.  g.  syphilitic,  post-poliomyelitic). 

The  grant  for  the  investigation  and  its  publication  is  from  a  private  endowment 
of  the  Massachusetts  School  for  the  Feeble-minded.  A  grant  for  publication  of  suitable 
and  numerous  plates  has  been  received  from  Dr.  W.  N.  Bullard,  whom  we  would  like 
to  thank  in  fullest  measure. 

Walter  E.  Fernald, 
E.  E.  Southard, 

Editors. 


I. 


GENERAL   ASPECTS  OF  THE  BRAIN   ANATOMY  OF  THE 

FEEBLE-MINDED. 

E.   E.   SOTJTHABD. 


I. 

GENERAL  ASPECTS  OF  THE  BRAIN  ANATOMY  OF  THE  FEEBLE-MINDED. 

E.  E.  Southard. 

Abstract. —  Small  amount  of  intensive  anatomical  work  available  in  the  literature  (Bourneville, 
Hammarberg,  Tredgold,  Bolton).  Research  emphasis  on  other  aspects  (heredity,  mental  tests,  social 
service,  education). 

Situation  in  the  biology  of  feeble-mindedness  (Ballantyne).  The  question  whether  any  feeble- 
minded persons  have  normal-looking  brains.  Relative  absence  of  work  on  the  brains  of  feeble-minded 
of  higher  grades.     Modern  knowledge  of  cortex  topography. 

Tredgold's  distinction  of  primary  and  secondary  amentia  ("germinal  blight"  versus  "arrest"). 
Classification  of  W.  W.  Ireland.  Exogenous  nature  of  numerous  cases  (intrauterine  lesions).  Tredgold's 
view  that  germinal  variations  are  pathological  and  not  spontaneous.  The  suggestion  that  germ  cells 
may  be  poisoned.     Brain  findings  in  exogenous  cases. 

Anatomical  classification,  Bourneville,  1889;  Bourneville's  researches.  Hammarberg's  report  on 
9  cases  (psychic  defects  connected  with  defective  nerve  cells  in  the  cerebral  cortex).  Idiocy  thought 
to  be  due  to  developmental  check  in  later  foetal  life.  Marked  weak-mindedness  thought  to  be  due  to 
arrest  of  development  in  a  stage  normal  for  the  first  years  of  life.  A  third  group  with  focal  factors  of 
inhibition  occurring  during  the  first  year  of  life. 

Most  of  Hammarberg's  work  devoted  to  the  microscopy  of  the  normal  cortex.  Necessity  of  recog- 
nizing certain  shrinkage  processes  as  artificial.  Hammarberg's  claim  that  disorderly  arrangement  of 
cortical  cells  is  also  found  in  normal  material  (undeveloped  cells  frequently  taken  for  atrophic  ones). 

Summary  of  Hammarberg's  work  with  4  cases  of  idiocy,  2  of  marked  weak-mindedness,  3  of  slighter 
degrees  of  weak-mindedness. 

Tredgold's  conclusion  that  the  essential  basis  of  primary  amentia  is  cellular,  due  to  an  imperfect 
or  arrested  development  of  cerebral  neurones.  Tredgold's  belief  that  irregular  arrangement  of  cells 
is  characteristic  of  feeble-mindedness  material. 

Situation  in  the  anatomy  of  feeble-mindedness  as  presented  at  the  Medical  Congress  in  Paris  in  1900. 

Work  of  Mierzejewski  (anatomical  lesions  are  developmental  deviations).  Mierzejewski's  special 
group  of  cases  in  which  the  gray  matter  is  disproportionately  large  as  compared  with  the  white  matter. 
Heterotopia. 

Classification  of  Shuttleworth  and  Fletcher-Beach;  microcephaly  probably  not  caused  by  prema- 
ture synostosis  of  cranial  sutures.  Congenital  hydrocephalus  extends  the  lateral  ventricles  lengthwise, 
acquired  vertically  and  transversely  (Meynert);   scaphocephaly;   Mongolian  idiocy;   other  groups. 

Syphilis  not  a  common  cause  of  feeble-mindedness;  juvenile  general  paresis  as  first  observed  by 
Clouston;   traumatic  cases;   so-called  hypertrophy. 

American  literature.  Wilmarth's  study.  25  cases  in  100  yielded  no  brain  lesions  to  gross  analysis. 
Quotations  from  Wilmarth's  conclusions. 

Problems  suggested  by  the  literature  of  the  brain  anatomy  of  the  feeble-minded. 


26  SOUTHARD. 

We  present  herewith  the  first  section  of  the  Waverley  Researches  in  the  Anatomy 
of  the  Feeble-Minded  begun  in  1913  under  the  auspices  of  the  Massachusetts  School  for 
the  Feeble-Minded.     This  first  section  of  Researches  contains 

I,  a  general  introduction  to  the  topic  of  brain  anatomy  of  feeble-mindedness, 

II,  a  particular  description  of  ten  instances  of  feeble-mindedness  of  various  grades, 
together  with  autopsy  and  microscopic  findings,  and 

III,  attempts  at  correlating  the  brain  anatomy  and  histology  with  clinical  and  espe- 
cially with  psychometric  (mental  test)  findings.  Further  studies  are  under  contempla- 
tion with  the  object  of  gradually  enlarging  the  brain  series,  from  which,  when  it  shall 
have  contained  say  50  brains,  we  may  be  able  to  draw  sound  conclusions. 

Let  us  note  at  the  outset  our  surprise  at  the  extraordinary  neglect  into  which  this 
topic  has  fallen.  Bourneville,  Hammarberg,  Wilmarth,  are  the  older  names  of  workers 
contributing  carefully  sifted  cases  studied  in  the  interest  of  feeble-mindedness.  Most 
authors  deal  with  feeble-mindedness  as  a  stalking-horse  in  some  other  scientific  pursuit, 
teratological,  embryological,  anatomical,  histological,  etc.  We  claim  for  the  present  work 
that,  despite  numerous  theoretical  and  ancillary  interests,  we  have  studied  feeble-mindedness 
from  the  stand-point  of  feeble-mindedness.  In  particular  we  have  tried  to  place  our  cases 
in  a  tentative  order  of  mental  strength,  correlating  brain  appearances  with  mental  tests. 
Our  purpose  has  been  at  least  as  much  to  evaluate  the  mental  tests  by  throwing  their 
results  against  the  brain  pictures  as  it  might  have  been  to  evaluate  the  brain  pictures  in 
the  light  of  mental  tests.  We  may  anticipate  our  conclusions  so  far  as  to  say  that,  roughly 
speaking,  the  architectonic  order  in  which  the  brains  arranged  themselves  corresponds 
to  the  psychometric  order  indicated  by  the  mental  tests. 

Thus,  we  must  emphasize,  we  are  not  here  studying  the  brain  for  the  brain's  sake, 
or  the  mental  tests  for  their  sake  alone.  We  have  no  eugenic,  economic  or  social  interests 
paramount  in  the  present  inquiry. 

This  first  series  of  ten  cases  is  intended  as  an  orienting  and  introductory  series  to  a 
more  extended  study  which  at  present  contemplates  the  examination  by  modern  methods 
of  40  more  cases,  to  make  up  a  series  of  50,  from  which  series  it  may  be  safe  to  draw  pro- 
visional conclusions.  The  first  series  has  accordingly  been  made  to  include  all  available 
material  from  several  sources  which  was  found  to  comport  with  certain  necessities  of 
modern  research  in  feeble-mindedness. 

One  might  readily  get  the  impression  that  the  literature  would  be  found  to  contain 
enough  properly  examined  material  from  which  to  draw  conclusions.  One  would  have  in 
mind  the  Bicetre  reports  of  Bourneville,  beginning  in  1881  and  continued  at  successive 
intervals_for  20  years.     One  would  have  in  mind  the  masterly  work  done  in  Sweden  by 


WAVERLEY   RESEARCHES.    I. 


27 


Hammarberg  and  published  after  his  death  at  Upsala  in  1895.  Another  source  of  in- 
formation would  be  the  work  done  by  Dr.  A.  F.  Tredgold  under  the  London  County 
Council  early  in  this  century  and  published  in  Mott's  Archives  of  Neurology  in  1903, 
embodied  in  Tredgold's  book  on  Mental  Deficiency,  second  edition,  1914. 

Then  one  would  find  the  work  of  J.  S.  Bolton  "On  the  Histological  Basis  of  Amentia 
and  Dementia,"  published  in  the  same  volume  of  Archives  of  Neurology  and  later  em- 
bodied in  a  more  popularized  form  in  Bolton's  book  "On  the  Brain  in  Health  and  Disease," 
London,  1914. 

In  the  textbooks  on  feeble-mindedness,  one  would  find  numerous  references  to  Italian 
work  in  anatomy.  In  various  textbooks  one  would  find  references  to  considerable  work 
on  the  anatomy  of  feeble-mindedness  (see  for  example,  the  literary  references  in  Ziehen's 
account  of  "Diseases  of  the  Brain  and  Meninges  in  Childhood,"  1912). 

In  point  of  fact,  however,  the  anatomy  of  feeble-mindedness  has  not  been  attacked 
systematically  over  a  period  of  years  having  due  regard  not  only  to  clinical  features, 
but  to  anatomical  and  histological  features. 

On  the  whole,  the  remarkable  developments  in  education  of  the  feeble-minded  fol- 
lowing the  initial  work  of  Seguin  have  developed  almost  independently  of  the  anatomical, 
histological  and  physiological  sides  of  the  topic.  With  the  developments  of  recent  years 
a  tremendous  emphasis  has  begun  to  be  laid  upon  the  hereditary  and  eugenic  aspects  of 
feeble-mindedness,  and  a  large  effort  has  been  expended  upon  certain  applications  of 
psychology  to  the  mental  testing  of  the  feeble-minded.  But  neither  the  hereditariana 
nor  the  applied  psychologists  have  particularly  concerned  themselves  with  the  broader 
biological  aspects  of  the  whole  topic.  We  must  confess  that  on  the  whole,  the  broader 
biological  aspects  of  feeble-mindedness  have  tended  to  be  concealed  in  the  mass  of  practi- 
cal applications  which  the  mental  testing  methods  have  unfolded  and  the  web  of  promises 
spun  by  the  eugenist.  Accordingly  we  face  a  situation  with  the  feeble-minded  in  which 
their  education,  their  heredity,  and  the  methods  of  their  mental  testing  have  absorbed 
interest.  In  the  spring  of  1915,  however,  the  note  of  research  in  this  field  was  struck 
at  the  National  Conference  of  Charities  and  Correction,  perhaps  somewhat  to  the  as- 
tonishment of  the  listeners,  who  have  been  far  more  interested  in  social  service  than  in 
the  more  recondite  aspects  of  research.  However,  educational  research,  eugenic  research, 
research  in  applied  psychology,  and  sociological  research,  all  need  effort  on  the  biological 
basis.  It  seems  as  if  this  basis  had  been  sadly  and  almost  inconceivably  neglected  in  the 
past. 

What  is  the  present  situation,  biologically  speaking?  The  biologist,  if  asked  the 
nature  and  measure  of  his  interest  in  feeble-mindedness,  would  be  apt  to  answer  some- 


28  SOUTHARD. 

what  as  follows:  The  institutions  might  supply  us  with  a  vast  deal  of  material  of  the 
greatest  interest  from  such  a  standpoint,  for  example,  as  that  of  Ballantyne,  whose  funda- 
mental collection  of  material  on  "Antenatal  Pathology  and  Hygiene"  was  published  in 
1902  and  1904  respectively.  There  should  be  much,  the  biologist  might  continue,  of 
great  interest  from  the  standpoint  of  monstrosities,  and  the  teratologist  might  be  able  to 
unravel  any  number  of  intricate  problems  of  the  mechanics  of  development  from  the 
anatomical  material  of  institutions  for  the  feeble-minded.  He  would  have  to  consider 
not  merely  the  immediate  pathology  of  the  antenatal  period,  but  also  the  postponed 
effects  which  Ballantyne  has  emphasized,  and  not  only  the  postponed  effects  in  the  neo- 
natal period  of  life,  but  also  its  postponed  effects  upon  still  later  life. 

Ballantyne  was  able  to  determine  important  relations  of  antenatal  pathology  to  no 
less  than  seventeen  departments  of  science  (see  his  figure  3,  page  18).  Of  the  considera- 
tions in  TarufR's  Storia  della  teratologia  would  come  an  application,  and  the  further 
development  in  studies  of  the  idiot  types  with  the  methods  available  to  modern  research. 
For  example,  the  microscopy  of  all  types  of  terata,  described  in  chapters  14-30  of  book  3 
of  Ballantyne's  volume  on  the  Embryo  would  get  a  new  importance  if  proper  histological 
studies  were  carried  out.  But  withal,  the  teratologist  would  be  studying  this  material 
from  the  standpoint  of  teratology  and  tissue  mechanisms,  and  the  fate  of  the  feeble- 
minded as  such  would  not  be  visibly  altered  for  the  better  in  a  long  period  of  years. 

The  pathologist  might  see  not  only  the  importance  of  antenatal  pathology  in  the 
direction  of  monstrosities,  but  he  might  be  greatly  interested  in  what  Ballantyne  has 
termed  the  intrusion  of  the  antenatal  factor  in  neonatal  disease  as  shown  by  instances 
of  intracranial  traumatism  and  intranatal  infections  (ophthalmia  neonatorum,  etc.). 
The  pathologist  would  also  be  interested  in  the  neonatal  infections,  such  as  sepsis  neo- 
natorum, as  also  very  particularly  in  what  Ballantyne  has  called  the  disturbed  antenatal 
readjustments,  such  as  icterus  neonatorum,  and  the  like.  Here  again  the  interest  in  the 
anatomy  of  the  feeble-minded  would  be  an  interest  derived  ab  extra.  The  pathologist 
must  go  to  the  specialist  in  feeble-mindedness  for  his  material  and  carry  his  interest  to 
that  material.  Hence  from  the  pathological  side  it  can  hardly  be  hoped  that  there  will 
be  a  tremendous  flow  of  new  work  on  this  topic. 

Again,  the  embryologist  must  be  interested  in  the  subject,  as  is  clear  throughout  both 
volumes  of  Ballantyne's  work;  but  the  embryologist  has  so  far  shown  little  interest  in 
what  has  sometimes  been  termed  "late"  embryology,  confining  his  attention  to  the 
plentiful  and  unsolved  problems  of  the  earlier  months.  Hence  what  happens  to  the  hypo- 
plastic organ  in  the  viable  victim  of  feeble-mindedness  is  of  less  immediate  interest  to  the 
embryologist  by  reason  of  the  embryologist's  comparative  ignorance  of  late  embryology 


WAVERLEY   RESEARCHES.    I. 


29 


in  general  and  hence  of  the  appearances  in  organs  sufficiently  developed  to  permit  their 
bearers  to  live. 

It  might  be  thought  that  the  physiologist  would  take  a  tremendous  interest  in  a 
number  of  aspects  of  feeble-mindedness  since  he  would  perhaps  be  able  to  find  the  differ- 
ential effects  of  imperfect  glands  of  internal  secretion  and  a  variety  of  simplified  phenomena 
of  nervous  and  circulatory  reactions.  On  the  whole,  however,  the  physiologist  probably 
feels  that  his  knowledge  of  these  matters  in  laboratory  animals  remains  too  tenuous  to 
permit  carrying  the  standard  far  afield  in  feeble-mindedness. 

The  zoologist  and  even  the  botanist  of  course  have  the  greatest  interest  in  the  germ 
cells,  their  development  and  interferences  with  their  development.  In  various  writers 
one  discovers  tendencies  to  the  thought  that  there  is  a  pathology  of  the  germ  plasm  which 
at  first  sight  spoils  the  simplicity  of  the  Weismannian  doctrines  about  the  immortality 
and  comparative  immutability  of  the  germ  plasm.  The  interest  in  eugenics  has  fortified 
this  interest,  and  no  doubt  all  the  germ  cell  biologists  as  well  as  the  eugenists  have  fully 
in  mind  the  value  of  studies  in  the  ancestry  and  familial  traits  of  the  feeble-minded. 
Nevertheless  these  interests  have  not  crystallized  into  a  theory  or  plan  of  attack  as  to 
feeble-mindedness. 

Like  the  child  in  Kipling,  each  science  or  art  above  mentioned  has  mysterious  errands 
of  its  own;  hence  it  seems  likely  that  the  workers  in  feeble-mindedness  themselves  must 
organize  then-  own  researches.  Where  then  should  research  in  feeble-mindedness  begin? 
There  is  no  lack  of  interest  in  the  education  of  the  feeble-minded.  There  is  no  lack  of 
interest  in  various  forms  of  social  service,  whether  it  takes  shape  as  help  for  the  individual, 
aid  to  the  public  purse,  or  an  attempt  to  safeguard  society.  There  is  no  lack  of  interest 
in  heredity  and  eugenics.  There  is  no  lack  of  interest  in  the  general  administrative 
problem  which  offers  one  of  the  most  productive  regions  for  the  administrator  in  the 
whole  field  of  public  service.  There  is  no  lack  of  interest  in  applied  psychology  as  it  has 
culminated  in  such  mental  tests  as  those  of  Binet,  de  Sanctis,  Healy,  Terman,  and  Yerkes. 
Little,  however,  has  ever  been  said  in  favor  of  a  consistent  attack  on  the  anatomy  and 
physiology .  of  the  feeble-minded. 

The  present  researches  form  a  comparatively  modest  introduction  to  that  highly 
desirable  attack  upon  the  physical  aspects  of  feeble-mindedness  which  have  been  so  in- 
conceivably neglected  in  the  past.  We  feel  that  it  is  wise  to  concentrate  attention  upon 
brain  anatomy  for  the  present,  despite  the  fact  that  the  ultimate  value  of  physiological 
work,  notably  in  the  field  of  the  glands  of  internal  secretion  may  be  immeasurably  greater. 
However,  in  a  number  of  fields  of  neuropathological  and  psychiatric  research,  we  have 
found  that  much  time  can  be  saved  if  the  physiologist  and  clinician  can  have  the  advantage 


30  SOUTHARD. 

of  knowing  whether  they  deal  on  the  one  hand  with  entirely  abnormal  brains  or  on  the 
other  hand  with  relatively  normal  ones.  This  dichotomy  of  the  material  is  rather  apt 
to  leave  one  with  three  groups  of  material,  —  a)  material  with  gross  lesions  of  an  obvious 
and  striking  nature;  b)  material  with  lesions  of  a  doubtful  and  questionable  character, 
and  c)  material  without  obvious  evidence  of  disease.  The  worker,  whether  he  deal  with 
insanity,  epilepsy,  criminal  anthropology  or  any  other  major  field  touching  the  nervous 
system,  finds  it  convenient  to  utilize  various  fundamental  studies  in  the  two  limiting 
groups  in  the  series,  viz.,  the  group  of  cases  with  obvious  gross  lesions  and  the  group  of 
material  with  no  obvious  lesions.  He  must  leave  the  intermediate  or  non-interpretable 
group  on  one  side  at  the  beginning  of  his  research. 

The  topic  of  feeble-mindedness  is  rendered  difficult  by  the  fact  that  the  observer 
apparently  cannot  compare  abnormal  material  with  normal  looking  material  just  by 
reason  of  the  absence  of  any  normal  looking  material.  At  least  an  observer  like  Tred- 
gold  remarks  that  he  has  never  "yet  seen  the  brain  of  an  idiot,  a  low  or  even  medium 
grade  imbecile  which  could  be  regarded  as  normal  upon  careful  naked-eye  examination" 
(of  course  it  will  be  noted  that  Tredgold  does  not  here  speak  of  the  imbeciles  of  higher 
grade  and  of  the  feeble-minded  proper).  It  is  safe  to  say  that  from  the  literature  one 
cannot  for  the  present  assert  whether  or  not  the  brains  of  imbeciles  of  higher  grade,  of 
the  feeble-minded  proper  or  so-called  morons,  or  of  the  dullards  or  simple-minded  per- 
sons who  grade  somewhat  higher  than  the  former,  have  normal  looking  brains.  Beyond 
question,  however,  most  workers  distinguish  at  least  roughly  between  the  idiots  and 
imbeciles  of  lower  grade  who  are  virtually  bound  to  show  obvious  brain  lesions,  and  the 
higher  grades  of  feeble-minded,  who  may  or  may  not  show  such  lesions.  In  either  case 
there  is  a  tendency  to  the  belief  that  amongst  the  higher  grades  will  be  found  persons 
whose  feeble-mindedness  tends  toward  functionality  as  a  limit.  There  is  a  tendency  to 
the  belief  that  the  higher  grades  of  feeble-minded  are  persons  whose  brains  are  fairly  well 
developed  in  the  sense  of  having  a  full  complement  of  cells  like  their  normal  brethren, 
but  whose  cells  do  not  for  some  reason  work  properly  or  have  not,  for  some  reason,  devel- 
oped their  full  panoply  of  processes.  That  there  is  a  group  of  feeble-minded  subjects 
that  in  a  sense  correspond  to  idiopathic  epileptics  or  to  the  so-called  functional  psycho- 
paths (for  example,  victims  of  manic  depressive  psychosis  of  modern  conception),  or  like 
the  delinquents  whose  brains  are  working,  as  it  were,  perversely,  without  structural  basis 
for  the  perversity,  amounts  even  to  a  working  hypothesis  with  many  observers.  Upon 
this  working  hypothesis  is  founded  a  number  of  conceptions  as  to  the  educability  and 
comparatively  good  prognosis  of  certain  feeble-minded  subjects  "under  proper  condi- 
tions" or  with  an  "improved  environment."     Whether  there  is  an  environmental  group 


WAVERLEY   RESEARCHES.    I.  31 

of  feeble-minded  subjects,  whether  there  is,  as  it  were,  an  idiopathic  or  functional  group 
of  these  cases,  is  an  open  question.  Just  as  we  suspect  that  there  are  frank  psychoses 
which  have  their  bases  not  in  structural  brain  disorder  but  in  exogenous  factors  working 
from  outside  the  brain,  so  we  may  theoretically  conceive  that  there  are  feeble-minded 
subjects  in  the  same  logical  group.  However,  in  a  general  way,  the  concept  of  "discords 
played  on  a  good  instrument"  is  not  a  concept  which  appears  to  have  a  wide  scope  in 
feeble-mindedness. 

The  literature  does  not  lack  work  of  a  systematic  and  comparative  nature  upon  idiocy. 
One  has  only  to  remember  the  work  of  Hammarberg  above  noted.  The  literature  lacks 
consistent  studies  of  feeble-mindedness  of  higher  grade  from  the  anatomical  and  histologi- 
cal points  of  view.  This  task  should  be  one  of  the  major  ones  of  the  present  undertaking. 
Hammarberg's  work  was  one  of  the  first  pieces  of  work  not  only  in  the  anatomy  and 
histology  of  feeble-mindedness  but  in  the  topographical  histology  of  the  nervous  system. 
The  topographical  histology  of  the  nervous  system  has  only  been  thoroughly  staked  out 
within  the  present  century.  The  idea  of  the  brain's  differential  topography  doubtless 
lay  completely  in  the  minds  of  such  workers  as  Bevan  Lewis,  Betz,  Meynert,  Cajal  and 
Nissl  in  the  nineteenth  century.  Early  in  the  present  century,  systematic  works  like 
those  of  Campbell,  Brodmann  and  Cajal  began  to  appear  and  to  have  currency.  These 
works  on  topographical  histology  were  supported  by  such  brain  anatomists  as  Elliot 
Smith  and  Ariens  Kappers,  as  well  as  by  the  comparative  anatomist,  Edinger.  The 
idea  of  cerebral  cortex  mapping,  of  a  kind  of  cartography  of  the  brain,  has  now  obtained 
a  firm  foothold  in  neurology  and  neuropathology.  It  must,  however,  be  accredited  to 
the  science  of  feeble-mindedness  that  the  lamented  Hammarberg  was  one  of  the  first 
histologists  who  saw  the  importance  of  such  cortex  mapping  and  began  his  work  upon 
the  material  of  idiocy.  To  be  sure  it  will  be  many  years  before  a  properly  equipped 
institute  carries  out  the  inchoate  aims  of  Hammarberg  and  the  aims  which  we  can  all 
now  so  clearly  see  when  we  associate  in  conception  the  material  of  feeble-mindedness  with 
the  modern  differential  work  on  cortex  structure. 

One  of  the  most  fruitful  distinctions  in  feeble-mindedness  of  the  present  day  is  that 
of  Tredgold,  who,  seeing  the  inadequacy  of  the  distinction  of  the  feeble-minded  into  con- 
genital and  acquired  cases  has  replaced  this  dichotomy  with  a  new  and  different  one, 
namely,  with  a  division  into  what  he  calls  primary  and  secondary  amentia. 

The  primary  aments  are  victims  of  what  is  sometimes  termed  "germinal  blight," 
whereas  the  secondary  aments  are  victims  of  some  cause  working  from  outside  the  brain. 
The  primary  ament,  according  to  Tredgold,  has  cells  with  an  intrinsic  vital  deficiency, — 
cells  which  are  unable  to  develop.     The  secondary  ament  is  the  victim  of  arrest,  due  to 


32 


SOUTHARD. 


some  external  cause.  One  might  say  that  the  cells  of  the  ament,  if  this  distinction  of 
Tredgold  can  be  upheld,  have  "run  down"  or  ceased  to  develop  at  a  certain  point, 
whereas  the  cells  of  the  secondary  ament  have  not  run  down  of  themselves,  but  have 
run  counter  to  some  agent;  that  is,  the  cells  have  not  ceased  to  develop,  they  have  been 
stopped.  The  distinction  reminds  one  of  the  simple  nomenclature  apparently  introduced 
into  neurology  by  Moebius,  namely,  the  distinction  between  cases  of  endogenous  and 
cases  of  exogenous  origin.  One  deals,  as  it  were,  with  a  plastic  impotence,  an  agenesia, 
in  the  case  of  the  primary  ament;  one  deals  with  a  sort  of  plastic  arrest  or  aplasia  in  the 
case  of  the  secondary  ament. 

The  value  of  this  distinction  of  Tredgold's  is  that  the  older  heterogeneous  anatomical 
classifications  of  the  feeble-minded,  such  as  were,  for  example,  available  to  W.  W.  Ire- 
land in  his  book  on  the  "Mental  Affections  of  Children"  can  be  supplanted  by  a  simpler 
classification  with  a  number  of  new  research  possibilities.  Ireland,  for  instance,  speaks 
of  genetous  idiocy,  namely,  idiocy  in  which  the  disease  condition  which  entails  deficiency 
of  mind  is  complete  before  birth,  and  in  which  accordingly  the  presumption  of  the  heredi- 
tary connection  is  stronger  than  in  other  forms.  Another  chapter  deals  with  micro- 
cephalics, a  third  with  hydrocephalics,  a  fourth  with  eclampsic  idiots,  a  fifth  and  sixth 
with  epileptic  and  paralytic  idiots,  and  further  chapters  with  traumatic,  inflammatory, 
sclerotic,  syphilitic  and  cretinistic  idiots,  and  the  last  chapter  with  what  Ireland  terms 
idiocy  by  deprivation  (namely,  that  condition  of  mind  in  which  a  child  remains  who  is 
deprived  of  two  or  more  of  the  principal  senses). 

According  to  Tredgold  a  great  number  of  the  intrauterine  causes  of  feeble-mindedness 
are,  as  it  were,  equally  exogenous  to  the  feeble-mindedness  as  would  be  a  cause  operating 
early  after  birth.  The  antenatal  and  neonatal  pathology  of  feeble-mindedness  would 
have  to  be  separated  into  a  congenital  and  acquired  group  forthwith,  unless  we  adopt 
Tredgold's  distinction  and  consider  that  numerous  antenatal  causes,  such  as  foetal  sepsis, 
foetal  syphilis,  and  the  like  are  just  as  secondary  in  their  effects  as  would  be  these  condi- 
tions in  the  neonatal  period.  Tredgold  accordingly  distinguishes  an  intrinsic  from  an 
extrinsic  group  and  would  probably  subscribe  to  Moebius'  terms  "endogenous"  and 
"exogenous"  as  equivalents  of  his  own.  In  his  original  discussion  of  amentia  in  Mott's 
Archives  in  1903,  he  had  already  practically  distinguished  the  intrinsic  forms  as  due  to 
the  condition  of  the  germ  plasm  and  the  extrinsic  forms  as  due  to  the  environment,  which 
environment  he  divided  into  antenatal,  intranatal  and  postnatal.  But  in  his  textbook 
Tredgold  states  that  the  real  question  is  as  to  the  respective  influences  exerted  by  heredity 
and  by  environment  and  proposes  that  the  terms  "congenital"  and  "acquired"  be  given 
up.     Tredgold  defines  extrinsic  causes  as  any  factors  of  the  environment  which  are  cap- 


WAVERLEY  RESEARCHES,    t.  38 

able  of  prejudicially  affecting  the  brain  development  of  the  offspring  after  conception 
has  taken  place,  whether  these  factors  be  intra  or  extra-uterine.  Amentia  due  to  such 
causes,  Tredgold  terms  extrinsic  or  secondary  amentia. 

Tredgold's  employment  of  the  term  "hereditary"  is  possibly  somewhat  special  to 
him.  Primary  amentia  Tredgold  regards  as  not  "due  to  absence  or  suppression  of  some 
specific  germ  determinant"  such  as  some  Mendelians  assert,  but  "as  resulting  from  a 
diminished  germinal  vitality  in  consequence  of  which  development  tends  to  be  incom- 
plete." Inheritance  takes  the  form  of  the  "neuropathic  diathesis  or  innate  predisposi- 
tion to  neurotic  imperfection."  As  to  the  origin  of  the  germinal  impairments  that  lie 
at  the  foundation  of  the  intrinsic  or  primary  group  of  Tredgold,  we  have  a  number  of 
possibilities.  The  Royal  Commission  on  Feeble-mindedness  decided  that  "both  on  the 
ground  of  fact  and  of  theory,  there  is  the  highest  degree  of  probability  that  feeble-minded- 
ness is  usually  spontaneous  in  origin,  that  is,  not  due  to  influences  acting  on  the  parent  — 
and  tends  strongly  to  be  inherited."  Tredgold  regards  this  as  a  confession  of  ignorance. 
He,  however,  looks  upon  the  hypothesis  of  Davenport  that  "feeble-mindedness  is  not  a 
new  variation,  but  a  perpetuation  of  strains  defective  from  the  beginning"  as  not  ten- 
able. Tredgold  regards  the  germinal  variations  in  the  parents  of  the  feeble-minded  as 
pathological  variations,  as  a  vitiation  and  not  spontaneous.  He  regards  this  vitiation 
as  primarily  due  to  the  action  of  the  environment,  quoting  the  work  of  Paul  on  lead 
poisoning,  the  work  of  Fere'  on  the  effect  of  alcohol  on  incubating  eggs,  the  more  recent 
work  of  Stockard  upon  guinea  pigs  and  other  similar  work.  Not  only  may  the  germ 
cells  be  poisoned,  but  they  may  be  altered  by  a  variety  of  physical  conditions,  such  as 
temperature  and  non-toxic  chemical  agents.  Whether  or  not  Tredgold's  conception  of 
the  causes  of  what  he  has  termed  germinal  blight  are  as  he  thinks  environmental,  there 
can  be  no  doubt  that  it  is  extremely  valuable  to  separate  out  all  definitely  exogenous 
cases  from  a  residue  whose  cause  may  be  left  undefined. 

What  now  can  we  see  in  the  brains  of  primary  as  opposed  to  secondary  aments? 
In  the  secondary  types  of  feeble-mindedness,  we  shall  often  see  effects  of  inflammation, 
appearances  like  that  of  porencephaly,  hydrocephalus,  and  the  like,  which  must  appeal 
to  us  as  flowing  from  causes  operating  from  without  and  indicating  no  essential  vital 
deficiency  or  vitiation  of  germ  plasm,  and  we  shall  be  greatly  interested  to  determine 
the  nature  of  these  exogenous  processes  and  the  quality  and  extent  of  their  effects  upon 
the  brain  map.  In  the  light  of  these  irregularly  deficient  brains  we  should,  under  ideal 
conditions,  be  immensely  interested  to  learn  whether  the  mental  states  of  the  bearers 
of  these  brains  also  show  functional  cut-outs  and  losses  to  correspond  with  the  irregular 
defects  of  the  brain  lesion.     A  tremendous  number  of  neurological  problems  will  be  settled 


34 


SOUTHARD. 


and  a  deep  vista  of  new  problems  can  be  predicted.  Moreover,  we  should  learn  much 
by  extended  study  of  these  secondary  cases  from  the  standpoint  of  what  is  termed  in 
the  German  "  Korrekturbildung. "  We  shall  namely  be  interested  in  discovering  what 
effects  may  be  wrought  by  the  lack  of  structure  A  upon  the  condition  of  structure  B 
which,  under  normal  conditions,  grows  in  structural  and  functional  relation  to  A. 

But  suppose  there  be  no  demonstrable  exogenous  processes  and  no  basis  for  sup- 
posing an  exogenous  process  in  a  given  case.     What  now  will  be  found  in  the  brain? 

The  literary  sources  of  information  from  which  to  answer  this  question  are  not 
numerous.  We  must  first  resort  to  Bourneville's  volumes  on  Researches  in  Epilepsy, 
Hysteria  and  Idiocy,  published  in  the  form  of  Reports  from  the  Bicetre,  beginning  in  the 
year  1881.  These  reports  contain  numerous  cases  reported  as  fully  as  the  state  of  sci- 
ence permitted.  The  majority  of  the  autopsy  reports  in  the  earlier  years  deal  with 
epileptics.  Numerous  remarkable  cases  of  tuberous  sclerosis  (sometimes  called  Bourne- 
ville's Disease)  are  described  and  photographed.  The  majority  of  these  cases  of  tuberous 
sclerosis  were  victims  of  epilepsy  or  of  convulsions  in  some  form.  Numerous  reports 
are  scattered  through  the  series  dealing  with  myxedematous  idiocy.  Through  the 
eighties  Bourneville's  reports  contained  few  instances  of  case  reports  in  which  convul- 
sions were  not  prominent.  In  the  nineties  began  to  appear  more  numerous  reports  of 
idiocy  and  epilepsy  without  convulsions.  Special  studies  of  hydrocephalus,  porencephaly 
and  microcephaly  appear,  and  the  term  "symptomatic  idiocy"  is  frequently  used  in 
connection  with  such  cases. 

In  1891  Bourneville  presents  in  his  11th  volume  an  anatomical  classification  of  idiocy 
(communicated  at  the  International  Congress  of  Mental  Medicine  in  1889)  which  classi- 
fication has  8  chief  heads,  as  follows :  — - 

Idiocy  symptomatic  of  hydrocephalus;  of  microcephalus;  of  arrest  of  convolutional 
development;  of  congenital  malformation  of  the  brain  (porencephaly,  absence  of  corpus 
callosum,  etc.);  idiocy  symptomatic  of  hypertrophic  or  tuberous  sclerosis;  of  atrophic 
sclerosis  (A,  of  one  or  both  hemispheres,  B,  of  one  brain  lobe,  C,  of  isolated  gyri,  D,  of 
scl6rose  chagrine"  du  cerveau);  idiocy  symptomatic  of  chronic  meningitis  or  meningo- 
encephalitis; and  finally,  idiocy  with  pachy dermic  cachexia  (myxedematous  idiocy  con- 
nected with  absence  of  the  thyroid  gland).  It  can  readily  be  seen  how  much  of  this 
classification,  which  is  based  upon  fifteen  years  of  work  at  the  SalpetriSre  and  at  the 
Bicetre,  has  relation  to  those  aments  whom  Tredgold  would  readily  call  secondary  aments. 
Bourneville  and  his  collaborators  have  published  excellent  photographs  of  many  of  the 
cases  in  this  series  of  volumes.  From  time  to  time,  histological  descriptions  of  a  relatively 
elaborate  nature  accompany  the  reports  and  deal  with  questions  of  neuroglia  prolifera- 


WAVERLEY  RESEARCHES.    T.  35 

tions  and  the  like  in  quite  the  modern  manner,  which  is  the  more  remarkable  since  much 
of  the  work  was  done  before  the  vogue  of  neuroglia  studies  begun  by  the  publication  of 
Weigert's  book  on  Neuroglia  in  1895. 

The  reports  of  the  nineties  are  filled  especially  with  accounts  of  idiocy  symptomatic 
of  atrophic  sclerosis  and  of  chronic  meningitis.  Reports  upon  congenital  idiocy  are  on 
the  whole  infrequent  in  Bourneville's  volumes.  Such  a  case  published  in  volume  13,  1893, 
by  Bourneville  and  Dauriac  was,  for  example,  a  congenital  epileptic  idiot,  which  was 
almost  completely  asphyxiated  at  birth,  began  to  walk  at  8  and  completed  dentition 
at  10.  This  idiot  had  had  convulsions  at  8  months  followed  by  incomplete  paralysis 
of  the  right  side.  Contractures  of  all  limbs  with  athetotic  movements  had  supervened. 
Double  craniectomy  was  performed  for  therapeutic  purposes  in  the  thirteenth  year.  The 
autopsy  showed,  besides  the  effects  of  the  operation,  a  cerebral  atrophy  (weight  855 
grams),  or  as  Bourneville  says,  the  autopsy  findings  may  perhaps  better  be  said  to  have 
confirmed  the  diagnosis  "arrest  of  brain  development"  made  during  the  patient's  life. 
There  were  no  areas  of  sclerosis  or  induration  and  this  fact  is  taken  by  Bourneville  to 
corroborate  the  clinical  evidence  as  to  the  absence  of  any  severe  convulsions.  There 
were,  however,  certain  leathery  appearances  in  some  gyri,  notably  in  the  left  parietal  and 
frontal  regions  and  in  the  right  frontal  and  temporal  sphenoidal  regions. 

From  such  a  description  and  from  Bourneville's  own  remark  as  to  the  possible  diag- 
nosis of  cerebral  atrophy,  it  can  readily  be  seen  that  such  a  case  very  possibly  belongs 
in  the  group  of  secondary  aments  of  Tredgold,  although  the  condition  may  well  have 
been  congenital  in  the  usual  acceptance  of  that  term. 

In  1895  Bourneville  and  LeNoir  published  an  example  of  so-called  complete  con- 
genital idiocy  with  paraplegia,  contracture  and  deformity  of  feet.  The  brain  of  this  case 
is  described  by  Bourneville  as  having  been  reduced  to  the  greatest  simplicity,  "virtually 
down  to  the  elementary  convolutions."  Although  these  convolutions  are  in  general 
voluminous,  even  strikingly  voluminous,  and  the  sulci  are  of  a  proper  depth,  annectant 
convolutions  are  almost  completely  lacking.  Plates  are  presented  of  this  case  which 
died  at  18. 

In  1896  Bourneville  and  Ruel  present  another  case  of  "complete  idiocy,"  probably 
congenital.     The  brain  showed  neither  meningitis  nor  focal  lesions. 

In  1897  Bourneville  and  LeNoir  again  published  a  case  of  congenital  idiocy  due  to 
arrest  of  development,  and  state  that  the  brain  reveals  no  macroscopic  lesion.  Never- 
theless its  morphology  is  rudimentary  and  the  arrangement  of  the  convolutions  is  in 
many  places  abnormal.  These  might  serve  as  examples  of  the  few  available  reports 
concerning  cases  of  so-called  developmental  arrest  to  be  found  in  Bourneville's  series. 


36  SOUTHABD. 

Although  he  terms  these  cases  congenital  and  speaks  of  some  of  them  as  victims  of  de- 
velopmental arrest,  they  seem  on  the  whole  to  stand  nearest  to  the  cases  which  Tredgold 
would  be  inclined  to  term  primary  aments.  The  number  of  cases  of  myxedematous 
idiocy  and  of  various  forms  of  so-called  symptomatic  idiocy  with  atrophic  sclerosis  and 
meningitis  continue  far  to  outnumber  the  cases  of  congenital  nature.  In  passing  one 
can  only  comment  with  admiration  upon  the  breadth  of  Bourneville's  general  plan  of 
attack  on  his  problem,  combining  as  it  does  the  clinical,  therapeutic  and  anatomical 
ideals. 

We  shall  now  naturally  turn  to  Hammarberg  for  evidence  as  to  the  essential  nature 
of  these  two  groups  of  cases,  whether  on  the  one  hand  we  adhere  to  the  older  distinctions 
of  congenital  and  acquired  cases,  or  adopt  the  more  modern  distinction  of  primary  and 
secondary  amentia  proposed  by  Tredgold. 

Hammarberg's  monograph  was  published  in  Upsala  in  1895,  edited  by  Henschen, 
after  the  death  of  the  author  from  appendicitis.  His  work  appears  to  have  been  done 
a  few  years  after  his  graduation  in  medicine  and  to  represent  a  comparatively  brief  period 
of  intensive  endeavor.  His  report  deals  with  9  cases.  He  believed  that  he  could  prove 
in  all  cases  that  the  psychic  defect  could  be  connected  with  defective  nerve  cells  in  the 
cortex.  The  cortical  deficiency  he  considered  to  be  due  either  to  a  standstill  in  devel- 
opment at  some  antenatal  or  early  neonatal  stage,  in  consequence  of  which  but  a  small 
number  of  cells  were  permitted  to  arrive  at  high  development.  He  admitted  the  possi- 
bility that  cells  might  be  destroyed  during  the  process  of  mal-development. 

In  some  cases  development  had  been  checked  in  small  regions  by  agents  working 
in  a  limited  and  local  manner,  but  in  such  wise  that  the  total  development  of  the  cortex 
had  been  unfavorably  influenced.  If  the  check  in  development  occurred  in  the  latter 
stage  of  foetal  life,  psychic  development  in  the  subject  became  impossible  and  these  cases 
are  grouped  as  idiots,  "blodsinnig",  in  group  A.  Since  the  inhibiting  factor  acted  unequally 
in  different  parts  of  the  developing  brain,  a  variety  of  disorders  in  the  cranial  nerves  in 
locomotor  capacity  and  in  sensibility,  such  as  were  found  in  many  cases,  were  explicable. 

In  a  second  group  of  cases  the  cortex  had  not  been  permitted  to  arrive  at  a  degree  of 
development  more  than  one  normal  for  the  first  years  of  life.  These  are  cases  which 
Hammarberg  groups  as  markedly  weak-minded  (in  hohem  grade  Schwachsinnige) .  Such 
cases  also  exhibited  the  same  irregular  cranial  motor  and  sensory  disorders. 

A  third  group  of  cases  is  a  group  in  which  the  inhibitory  factor  is  thought  to  occur 
during  the  first  year  of  life  and  to  affect  only  a  small  region  of  the  brain.  The  rest  of 
the  brain  is  regarded  as  developing  properly  in  all  directions,  except  that  the  number  of 
cells  seems  to  remain  smaller  than  normal.     The  psychic  result  is  that  the  patient  is 


WAVERLEY   RESEARCHES.    I.  37 

inactive  and  less  developed  than  a  normal  person  of  the  same  age.  These  are  cases 
classified  under  B  2,  as  moderately  and  slightly  weakminded  {massig  und  in  geringem  grade 
Schwachsinnige) .     Similar  peripheral  disorders  are  found  in  these  cases  also. 

The  idiots  of  Hammarberg's  series  number  4, 

The  markedly  weakminded,  2, 

The  moderately  and  slightly  weakminded,  3. 

Although  there  are  a  number  of  drawings  of  gross  brains  in  plates  6  and  7  of 
Hammarberg's  monograph,  the  chief  direction  of  Hammarberg's  research  is  microscopic. 
Excellent  drawings  to  scale  of  preparations  from  various  areas  of  the  cortex,  stained  by 
methylene  blue,  are  presented  in  plates  1  to  5.  Plates  1,  2  and  3  deal  with  the  normal 
cortex  (since  it  must  be  remembered  that  Hammarberg's  work  antedated  the  cerebral  topog- 
raphy of  late  years)  and  deal  with  superior  and  inferior  frontal  gyri,  with  the  precentral 
gyrus,  the  superior  temporal,  the  superior  and  inferior  parietal  and  superior  occipital  gyri, 
the  central  lobe,  hippocampal  gyrus,  the  fascia  dentata,  cornu  ammonis,  fascia  cinerea, 
the  gyrus  cinguli  and  the  gyrus  centralis  superior. 

The  pathological  plates  are  4  and  5  and  contain  15  drawings  to  scale  of  a  number 
of  the  above  mentioned  areas.  The  whole  work  is  but  a  torso  of  what  Hammarberg 
would  doubtless  have  accomplished  had  he  lived. 

A  number  of  Hammarberg's  observations  as  to  the  microscopy  of  feeble-mindedness 
exhibit  a  very  modern  insight.  For  example,  he  dismisses  the  frequently  expressed 
notion  that  the  pericellular  and  perivascular  spaces  are  enlarged  about  the  brain  cells 
of  idiots,  whether  in  consequence  of  lymphatic  stasis  or  of  cellular  atrophy.  He  regards 
these  features  as  shrinkage  processes,  finding  them  to  occur  only  in  material  which  had 
at  some  stage  been  placed  in  alcohol  of  marked  concentration,  and  finding  similar  changes 
to  occur  in  normal  persons.  These  findings,  then,  are  dismissed  by  Hammarberg  as  arte- 
facts, and  it  is  probable  that  all  modern  workers  will  agree  with  him. 

A  second  statement  to  be  found  in  the  literature  preceding  Hammarberg  and  to 
some  extent  since  his  day  is  that  the  brain  cells  of  the  cortex  in  idiocy  present  a  disor- 
derly or  imperfect  arrangement,  so  that  the  apical  processes  he  at  right  angles  to  their 
normal  direction  or  obliquely.  Hammarberg  discovered  that  identical  appearances 
might  be  found  in  entirely  normal  material,  noting  especially  that  in  the  inferior  frontal 
gyrus  and  the  hippocampal  gyrus  such  apparent  disorder  in  the  orientation  of  cells  is 
normal. 

A  third  question  of  contention  in  the  literature  deals  with  the  occurrence  of  cellular 
atrophy,  vacuole  formation  and  pigmentary  degeneration,  but  such  changes  as  these  were 
found  by  Hammarberg  in  but  one  of  his  9  cases,  and  he  notes  that  undeveloped  cells  have 


38  SOUTHARD. 

frequently  been  taken  for  atrophic  ones,  especially  if  at  the  same  time  an  imperfect 
technique  has  produced  the  artefact  of  dilated  pericellular  spaces. 

Hammarberg  accordingly  dismisses  the  idea  that  the  nerve  cells  of  the  idiot  and 
imbecile  do  not  fill  enough  space  in  the  cerebral  cortex  in  which  they  are  embedded,  that 
they  are  especially  subject  to  irregular  orientation  therein,  and  that  they  are  necessarily 
subject  to  atrophy,  vacuole  formation  or  pigmentary  change. 

Hammarberg' s  conclusions  then  deal  with  four  cases  of  idiocy,  namely,  subjects 
deficient  in  all  the  higher  psychic  functions  and  incapable  of  psychic  development.  In 
three  of  these  cases  the  greater  part  of  the  cortex  was  in  a  stage  of  development  normally 
found  in  the  last  half  of  intra-uterine  life.  In  a  fourth  case  development  had,  according 
to  Hammarberg,  progressed  farther  and  had  reached  a  stage  found  normally  in  the  first 
year  of  life;  but  in  this  case  a  process  had  occurred  which  had  reduced  development  back 
to  the  same  stage  as  in  the  other  three  cases. 

The  second  group  of  cases,  two  in  number,  is  a  group  of  markedly  weak-minded 
subjects,  whose  mental  life  corresponds  to  that  of  normal  individuals  of  one  to  five  years 
of  age.  Their  cortex  was  found,  according  to  Hammarberg,  to  be  in  a  stage  of  develop- 
ment found  in  normal  individuals  during  the  same  years. 

The  three  cases  of  the  group  of  moderately  or  slightly  weak-minded  are  cases  in  which 
the  mental  functions  are  sluggish  and  somewhat  less  developed  than  in  normal  individuals 
of  the  same  age.  Such  subjects  are  capable  of  a  certain  amount  of  education.  Their 
degree  of  development,  from  a  mental  standpoint,  might  readily  be  compared  to  any 
special  stage  of  development  in  normal  individuals.  According  to  Hammarberg,  the 
number  of  nerve  cells  in  the  greater  part  of  the  cortex  is  much  less  than  normal  and  the 
remarkable  feature  of  the  general  brain  situation  is  that  in  one  particular  region  the  cor- 
tex will  be  found  to  be  in  a  stage  of  development  normally  appearing  in  the  very  first  year 
of  life.  Here  then  a  number  of  claims  appear  which  would  be  well  worth  substantiating 
by  extensive  studies. 

The  most  elaborate  recent  statement  concerning  feeble-mindedness  is  that  by 
Tredgold  in  his  book  on  "Mental  Deficiency".  The  ideas  are  largely  based  upon  special 
work  as  published  in  Mott's  Archives  of  Neurology,  Volume  2,  1903,  carried  out  in  the 
Claybury  Pathological  Laboratory  during  two  years'  tenure  of  the  London  County 
Council  Research  Scholarship  in  Insanity  and  Neuropathology.  Mention  has  been  made 
above  of  Tredgold's  conception  of  primary  and  secondary  aments.  He  regards  the  essen- 
tial basis  of  primary  amentia  as  cellular.  Such  gross  conditions  as  porencephaly,  hydro- 
cephalus, microgyria,  hemiatrophy,  and  the  like,  are  of  course  frequently  associated  with 
amentia,  but  they  are,  according  to  Tredgold,  accidental  associations  therewith.     "The 


WAVERLEY  RESEARCHES.     I.  39 

essential  basis  of  amentia  is  an  imperfect  or  arrested  development  of  the  cerebral  neurones." 
Tredgold  calls  attention  to  numerical  deficiency  in  cells  (compare  Hammarberg's  work), 
to  irregular  arrangement  of  cells  and  to  imperfect  development  of  cells,  giving  rise  to  the 
frequent  appearance  of  certain  cells  first  described  by  Bevan  Lewis,  or  to  some  still  more 
ill-developed  cells  which  correspond  with  early  neuroblasts.  Tredgold  states  that  the 
amount  of  change  discoverable  by  the  microscope  is  directly  proportionate  to  the  degree 
of  mental  deficiency  present  during  life.  Tredgold  also  ascribes  importance  to  pig- 
mentation, believing  that  it  is  an  indication  of  defective  metabolism  in  which  anabolic 
processes  cannot  keep  pace  with  the  catabolic. 

Hammarberg  and  Tredgold  are  accordingly  in  apparent  discord  as  to  the  significance 
of  irregular  arrangement  of  nerve  cells.  Tredgold  believes  that  his  own  experience  as 
well  as  that  of  several  others  makes  it  clear  that  an  irregular  and  haphazard  arrangement 
of  cortical  cells  is  very  characteristic  of  the  condition.  He  states  that  such  irregularities 
are  found  often  where  there  is  no  accompanying  sclerosis.  This  problem  of  the  irregular 
arrangement  of  nerve  cells  and  its  significance  accordingly  remains  a  problem  in  the 
minds  of  many  workers.  Doubtless  Tredgold  would  agree  with  Hammarberg  as  to  the 
non-characteristic  nature  of  the  pigmentation  found. 

As  to  two  points,  Hammarberg  and  Tredgold  are  then  in  comparative  agreement, 
namely,  that  numerical  deficiency  in  nerve  cells  is  a  major  feature  in  brains  of  feeble- 
mindedness and  that  the  cellular  appearances  indicate  imperfect  development.  If  we 
consider  the  problem  from  the  point  of  view  of  these  two  authors,  accordingly,  we  must 
spend  a  maximum  of  attention  on  the  number  of  cells  and  on  the  qualitative  appearances 
therein. 

We  cannot  pretend  at  this  time  to  deal  with  the  literature  of  the  anatomy  of  feeble- 
mindedness with  any  completeness,  although  we  have  had  the  advantage  of  the  relatively 
complete  index  of  the  literature  of  feeble-mindedness  possessed  by  the  Waverley  School, 
from  which  we  have  abstracted  over  eight  hundred  references  which  deal  pretty  speci- 
fically with  anatomical  problems.  We  present  below  a  selection  from  these  anatomical 
references,  having  chosen  those  that  relate  more  especially  to  the  types  of  case  considered 
in  the  first  series  of  ten  cases.  The  outstanding  work  of  Bourneville  and  of  Hammarberg 
as  above  mentioned,  and  the  systematic  treatment  of  Tredgold,  do  not  by  any  means 
exhaust  the  anatomical  interests  of  feeble-mindedness  as  presented  in  readily  accessible 
literature.  A  book  of  strongly  anatomical  trend  is  that  of  W.  W.  Ireland  called  "Mental 
Affections  of  Children",  wherein  are  given  a  number  of  points  of  view  of  permanent  value. 
Ireland's  classification  has  been  given  in  brief  above  in  the  discussion  of  Tredgold's  point 
of  view. 


40  SOUTHARD. 

Below  we  shall  consider  some  American  work  in  the  field,  before  which  it  may  be 
thought  desirable  to  consider  the  status  of  the  anatomy  of  feeble-mindedness  as  presented 
at  the  thirteenth  international  medical  congress  held  in  Paris  in  1900.  The  eighth  volume 
of  the  Comptes  Rendus  is  devoted  to  psychiatry.  There  were  three  special  questions 
proposed  to  the  psychiatrists  at  this  congress,  one  of  which  was  the  question  of  the  patho- 
logical anatomy  of  idiocy.  Reports  by  Mierzejewski,  of  St.  Petersburg,  of  Shuttle- 
worth  and  Fletcher-Beach  of  England,  and  of  Bourneville,  were  presented,  with  a  special 
contribution  to  histopathology  by  Philippe  and  Oberthiir. 

Mierzejewski  considered  that  Bourneville's  classification  based  upon  coarse  changes 
in  the  brain  might  well  correspond  to  practical  needs,  but  that  a  histological  classification 
based  upon  special  studies  and  upon  exact  embryological  conceptions  was  sure  to  develop 
in  the  future.  Mierzejewski  considered  that  the  basis  of  every  anatomical  lesion  in  the 
idiot's  brain  is  a  developmental  deviation  in  the  nerve  tissue.  Its  origin  must  be  sought 
in  embryonic  life  or  in  disease  occurring  in  earliest  infancy.  There  could  be  no  question 
of  any  true  arrest  of  development  without  its  morphological  and  histological  basis  in  the 
entire  brain.  There  could  be  determined,  however,  a  true  arrest  of  development  in 
certain  regions  as  indicated  by  the  presence  of  neuroblasts.  Mierzejewski  went  on  to 
describe  a  particular  group  of  cases,  namely:  those  in  which  the  white  substance  of  the 
cerebral  hemispheres  is  well  developed  but  the  gray  matter  of  the  cortex  is  distinguished 
by  appearing  in  enormous  and  disproportionate  amount.  It  was  true  that  such  brains 
belonging  to  microcephalic  or  demi-microcephalic  subjects  as  a  rule  showed  small  con- 
volutions (microgyria),  but  there  were  cases  of  this  disproportionate  development  of  the 
cortex  in  which  there  was  no  microgyria.  Mierzejewski  had  published  the  first  case  of 
this  nature  in  the  Comptes  Rendus  of  the  international  congress  at  Geneva  in  1877. 

The  Mierzejewski  type  of  idiot  brain  is  characterized  by  a  fairly  developed  centrum 
semiovale,  an  enormous  distension  of  the  ventricles,  with  the  cerebral  hemispheres  trans- 
formed into  a  species  of  thin-walled  vessel,  15  or  16  mm.  thick.  In  such  extreme  examples 
as  this,  there  is  always  microcephaly  as  well  as  microgyria,  but  there  are  other  cases  in 
which  the  white  substance  of  the  hemispheres  is  not  so  shallow  and  in  which  microgyria 
is  absent.  In  such  cases,  finer  methods  will  determine  a  lack  or  insufficient  development 
of  transverse  intracortical  medullated  fibres.  In  von  Monakow's  case,  there  were  neither 
any  tangential  fibres  nor  any  striations  of  Vicq-d'Azyr.  In  other  cases  these  structures 
were  more  or  less  well  developed. 

The  situation  was  identical  with  the  short  and  long  subcortical  association  fibres, 
absent  in  certain  examples,  more  or  less  developed  in  certain  others.  The  radial  bundles 
also  varied  in  their  development  in  these  cases. 


WAVEBLEY  RESEARCHES.    I. 


41 


The  gray  matter  presented  at  first  sight  the  appearance  of  making  up  for  the  insuf- 
ficiency of  the  white,  sometimes  presenting  all  its  characteristic  layers  with  perfect  dis- 
tinctness; in  other  cases  presenting  irregularity  of  arrangement. 

The  distinguishing  feature  of  these  hemispheres  was  the  interpolation  of  a  layer 
between  the  centrum  semiovale  and  the  cortex,  of  an  intermediary  strip  of  the  so-called 
neuroblasts;  or  in  certain  cases,  a  layer  of  cells  resembling  those  of  the  lower  layers  of 
the  cortex,  but  irregularly  arranged.  In  one  case  there  had  been  interposed  between  the 
new  layer  and  the  overlying  cortex  a  separate  strip  of  white  matter.  This  condition  of 
affairs  is  called  heterotopia  of  the  gray  matter.  Although  this  particular  form  of  hetero- 
topia is  diffuse,  it  does  not  resemble  that  more  frequent  form  of  heterotopia  in  which 
there  are  islets  of  ganglion  cells  scattered  through  the  white  matter.  The  microcephalic 
cases  of  microgyria  show  the  interpolated  layer  to  be  formed  of  "neuroblasts."  The 
demi-microcephalics  have  cells  in  the  interpolated  layer  which  resemble  the  so-called 
polymorphous  cells  of  the  undermost  layer  of  the  normal  cortex. 

This  Mierzejewski  type  of  microcephaly  is  accordingly  distinguished  from  the  ordi- 
nary microcephalic  brain  in  that  the  proportions  between  gray  and  white  matter,  more 
or  less  well  observed  in  the  usual  case,  are  not  preserved  in  the  Mierzejewski  types.  The 
demi-microcephalics  according  to  Mierzejewski  resemble  the  normal  more  closely  in  that 
the  arrest  of  development  on  the  part  of  the  white  matter  is  of  slighter  degree  and  is 
accompanied  by  a  diffuse  subcortical  heterotopia  of  gray  matter.  But  the  principle  is 
identical  in  both  types  of  case. 

Mierzejewski  goes  on  to  describe  in  more  detail  certain  microscopic  findings  in  a 
fresh  case  of  the  disease,  and  then  sums  up  somewhat  as  follows :  Idiocy  may  in  certain 
instances  accompany  a  condition  in  which  the  gray  matter  is  extremely  rich  and  in  which 
there  is  an  abundance  .of  nerve  cells.  In  these  cases  the  commissural  system  of  the  con- 
volutions is  arrested  in  development  so  that  there  are  not  a  sufficient  number  of  paths  of 
intercommunication  and  there  is  a  disharmonious  development  of  the  different  nervous 
elements.  In  the  central  nervous  system,  quantity  alone  does  not  count,  but  quality 
of  elements  and  quality  in  their  reciprocal  combinations  are  the  things  that  count.  The 
white  matter  is  nothing  but  a  mass  of  prolongations  of  the  nerve  cells;  accordingly  rich- 
ness of  the  dendritic  branchings  and  of  axis-cylinders  of  cells  is  the  condition  which  most 
favors  the  plentiful  development  of  white  matter;  and  when  these  ramifications  are  few 
in  number,  the  development  of  the  white  matter  is  insufficient.  One  of  the  chief  condi- 
tions for  irregular  processes  would  then  appear  to  be  the  multiplication  and  broad  expanse 
of  the  connections  of  the  pyramidal  cells.  Mierzejewski  attributes  to  Dejerine  the  idea 
that  intellectual  supremacy  seems  to  be  the  result,  not  so  much  of  the  number  of  cells, 


42  SOUTHARD. 

as  of  the  multiplicity  and  extent  of  their  inter-connections.  The  idiot  may  have  cells 
enough  though  these  are  deprived  of  their  proper  branchings.  Mierzejewski  throws  out 
the  suggestion  that  some  of  the  neuroblasts  lying  below  the  normal-looking  cortex  may 
now  and  then  proceed  to  a  further  development,  and  thus  explain  the  occasional  notable 
amelioration  of  mental  faculties  found  in  idiots. 

The  report  of  Shuttleworth  and  Fletcher  Beach  presents  a  classification  of  the 
pathological  anatomy  of  idiocy  under  three  main  headings:  (a)  Congenital;  (b)  De- 
velopmental; (c)  Acquired  or  accidental.  Among  the  congenital  cases  Shuttleworth 
and  Beach  enumerate  eight  forms. 

The  microcephalic  form  contains  cases  with  cerebral  hemispheres  shortened  in  such 
wise  as  to  reveal  the  cerebellum  viewed  from  above,  with  such  hindrance  of  development 
during  intrauterine  life  (probably  between  the  third  and  fourth  months  of  pregnancy) 
as  to  disturb  the  later  growth  of  the  hemispheres  as  well  as  the  detailed  development  of 
those  parts  which  had  been  already  formed.  It  is  perhaps  the  temporo-sphenoidal  and 
occipital  regions  which  suffer  most  (as  to  the  occipital  region,  Cunningham  and  Telford- 
Smith  are  quoted).  Microcephaly  is  probably  not  caused  by  the  premature  synostosis 
of  the  cranial  sutures.  On  the  other  hand,  the  development  of  the  brain  is  probably 
the  determining  factor  as  to  the  form  of  the  cranium  (H.  A.  Humphrey).  Microscopi- 
cally one  finds  simply  rounded  or  oval  cells  or  cells  with  but  few  dendrites. 

A  second  form  of  congenital  disease  is  hydrocephalus,  both  that  due  to  antenatal 
and  that  due  to  postnatal  conditions.  According  to  Meynert,  congenital  hydrocephalus 
extends  the  lateral  ventricles  lengthwise,  while  acquired  hydrocephalus  stretches  the 
ventricles  vertically  and  transversely.  Cases  of  Bourneville,  Beach,  and  Alexander  Hill 
are  quoted. 

A  third  form  of  congenital  disease  is  scaphocephaly,  a  condition  possibly  due  to  a  pre- 
mature union  of  the  sagittal  suture  with  an  exaggeration  in  the  growth  of  the  coronal  and 
lambdoid  sutures  in  such  wise  that  the  head  is  elongated  from  before  backwards,  and 
may  sometimes  increase  in  height.  But,  on  the  other  hand,  this  condition  may  possibly 
be  the  result  of  an  original  elongation  and  narrowness  of  the  cranium,  such  as  may  be 
found  in  the  natives  of  New  Caledonia,  the  New  Hebrides,  and  the  Carolines.  Sir  W. 
Turner  is  quoted  to  the  effect  that  this  cranial  form  is  due  to  intrauterine  causes,  such 
as  inflammation  or  injury  of  the  mother  during  pregnancy.  Scaphocephaly  does  not 
necessarily  produce  idiocy,  and  an  approximation  of  this  form  of  skull  may  be  found  in 
North  American  tribes  due  to  artificial  compression. 

A  fourth  type  of  congenital  disease  is  the  Mongolian  type,  with  its  special  bony, 
cutaneous,   mucosal,   and   cardiac   conditions.     Brachycephaly,   approximately  circular 


WAVERLEY   RESEARCHES.    I.  43 

in  circumference,  with  a  tendency  to  parallelism  of  the  parietal  and  occipital  surfaces,  is 
noted.  The  skull  is  thin.  There  is  an  anomalously  short  little  finger  with  lateral  incurving 
displacement  of  the  terminal  phalanx.  The  skin  is  coarse  and  scaly,  the  mucous  mem- 
brane irritable,  the  tongue  is  long,  marked  with  deep  folds,  due  to  hypertrophy  of  papillae. 
Cardiac  lesions  are  cited  from  cases  of  Garrod  and  of  Thompson.  Wilmarth's  work  is 
quoted  as  to  the  brains,  which  are  said  to  show  a  very  small  pons  and  medulla,  as  well 
as  very  thin  vessels.  Shuttleworth  thinks  that  these  Mongolian  idiots  are  essentially 
unfinished  children,  and  that  their  singular  appearance  is  that  of  a  phase  of  foetal  life. 

The  fifth  form  of  congenital  case  is  the  so-called  genetous  or  congenital  neuropathic 
form,  the  offspring  of  neurotic  parents.  These  cases  are  said  to  show  very  early  in  life 
excessive  irritability,  insomnia,  attention  disorder,  and  loss  of  self  control.  Such  sub- 
jects are  said  to  show  microgyria  at  autopsy. 

The  sixth  type  is  the  type  of  amaurotic  family  idiocy  of  Tay  and  Sachs. 

The  seventh  form  is  that  of  sporadic  Cretinism. 

The  eighth  form  is  a  form  presenting  partial  and  local  atrophies.  Examples  are  ab- 
sence of  corpus  callosum,  porencephaly,  cerebellar  aplasia,  and  the  like. 

In  addition  to  congenital  cases  Shuttleworth  and  Beach  then  consider  the  develop- 
mental group,  under  which  they  consider  eclamptics,  epileptics,  syphilitics  (including 
juvenile  paresis)   and  paralytics. 

They  consider  that  the  lesions  found  in  eclamptic  cases  associated  with  the  severe 
convulsions  of  dentition  are  local  hemorrhages  and  adherent  membranes  which  are 
inconsistent  with  the  normal  nutrition  of  the  gyri.  As  for  the  epileptic  group,  the  work 
of  Bevan  Lewis,  of  Andriezen,  and  of  Echeverria  is  quoted. 

Syphilis,  they  consider,  is  not  a  common  cause  of  idiocy,  but  juvenile  general  paresis 
they  regard  as  commonly  caused  by  syphilis.  They  state  that  since  Clouston  first  de- 
scribed this  latter  disease,  there  have  been  about  100  observations  published. 

The  majority  of  the  paralytic  group  of  the  developmental  cases  are  of  postnatal 
origin.     These  cases  are  attributed  to  inflammation  of  the  brain  or  the  meninges. 

In  the  third  group  of  accidental  or  acquired  cases,  Shuttleworth  and  Beach  consider 
three  forms:   traumatic,  postfebrile,  and  sclerotic. 

The  traumatic  cases  are  due  to  compression  of  the  head  during  prolonged  labor  or  to 
the  forceps.  The  lesions  are  situated  as  a  rule  in  the  Rolandic  region.  Small  hemor- 
rhages occur  which  are  followed  by  degeneration  and  sclerosis.  In  the  cases  of  cerebral 
diplegia,  the  most  frequent  cause  is  a  meningeal  hemorrhage  especially  affecting  the 
veins  between  the  pia  mater  and  dura  mater  in  the  longitudinal  sinuses,  in  such  wise  that 
the  hemorrhage  in  finding  its  way  into  the  great  fissure  compresses  the  upper  borders 


44  SOUTHARD. 

of  the  two  hemispheres.  The  opinion  of  Osier  and  of  Jacobi  is  quoted:  that  certain  of 
these  cases  are  actually  due  to  foetal  meningoencephalitis.  Intelligence  need  not  be 
markedly  affected  despite  the  severity  of  the  physical  disease. 

Under  the  heading  of  the  postfebrile  cases,  Shuttleworth  and  Beach  also  take  up  the 
cases  of  so-called  hypertrophy.  The  most  frequent  acute  infections  which  bring  about 
these  postfebrile  cases  are  smallpox,  typhoid  fever,  and  scarlet  fever.  Meningeal,  neu- 
roglia, and  nerve  cell  changes  are  noted  in  different  degrees.  The  relatively  rare  affection 
known  as  hypertrophy  of  the  brain  shows  an  increase  of  neuroglia  and  of  the  white  matter, 
but  the  nutrition  of  the  brain  seems  also  to  be  affected.  The  brain  looks  anaemic  on 
section  and  strikes  one  as  having  been  under  a  certain  pressure  within  the  skull,  showing 
flattened  and  compressed  gyri  with  sulci  effaced.  The  most  markedly  injured  part  of 
the  brain  is  the  white  matter  of  the  hemispheres.  The  head  does  not  reach  the  size  of 
the  head  in  hydrocephalus,  nor  is  the  increase  so  marked  in  the  temples  as  it  is  in  the 
superciliary  region.  The  hydrocephalic  head  is  rounded;  the  skull  in  hypertrophy  tends 
more  to  squareness.  In  hydrocephalus  the  distance  between  the  eyes  is  increased;  not 
so  in  hypertrophy. 

The  third  type  is  that  of  the  sclerotic  brains,  carefully  studied  by  Bourneville. 
Wilmarth  is  quoted  as  finding  in  500  autopsies  no  less  than  96  cases.  The  tuberous  form 
of  sclerosis  was  found  in  15  instances. 

Bourneville  presented  his  anatomical  point  of  view  under  the  following  ten  heads: 

1.  Meningitic  idiocy. 

2.  Meningoencephalitic. 

3.  Developmental  (simple  arrest). 

4.  Atrophic  sclerosis. 

5.  Hypertrophic  or  tuberous  sclerosis. 

6.  Porencephalic. 

7.  Pseudoporencephalic. 

8.  Myxedematous. 

9.  Congenitally  malformed. 
10.  Microcephalic. 

This  account  of  the  general  aspects  of  brain  anatomy  in  the  feeble-minded  might  be 
concluded  by  a  brief  reference  to  the  American  literature.  Besides  the  allied  but  sepa- 
rate topic  of  amaurotic  family  idiocy  or  Tay-Sachs  disease,  not  here  considered,  and  vari- 
ous case  reports  presented  largely  from  the  aspect  of  being  interesting  as  clinical  neu- 
rological phenomena  by   Mills,  Spiller,  Pearce,  and    others,  the  American  literature  is 


WAVERLEY  RESEARCHES.    I.  45 

devoid  of  much  systematic  work  except  that  of  Wilmarth  about  to  be  considered.  From 
Massachusetts,  a  few  cases  have  been  published  by  Bullard  and  one  by  Southard.  An 
interesting  attempt  was  made  by  Orton  in  his  "Pathological  Study  of  a  Case  of  Hydro- 
cephalus" to  parallel  the  cortex  mapping  of  the  topographers  (Campbell,  Brodmann, 
and  the  others)  by  a  similarly  conceived  study  of  a  markedly  hydrocephalic  case.  He 
showed  how  certain  portions  of  the  cortex  normally  sunken  below  the  surface  are,  as  it 
were,  ballooned  out  to  appear  on  the  surface  of  the  dilated  brain.  The  kind  of  work 
there  initiated  by  Orton  should  be  continued  and  performed  in  a  large  series  of  cases,  but 
such  work,  of  both  an  intensive  and  extensive  nature,  requires  the  resources  of  a  brain 
institute  to  execute. 

The  largest  series  of  cases  of  feeble-mindedness  as  yet  studied  in  America  from  the 
anatomical  point  of  view  is  unquestionably  the  series  reported  by  A.  W.  Wilmarth,  form- 
erly of  Elwyn,  Pa.  This  work  is  favorably  commented  upon  in  many  publications  on 
feeble-mindedness. 

Wilmarth  reported  in  1890  on  the  examination  of  100  brains  of  feeble-minded  children. 
The  following  table  shows  the  classification  employed  although  it  is  not  now  possible  to 
learn  which  cases  were  entered  twice  in  the  table. 

No  actual  disease  or  imperfect  development  of  the  brain 25 

Non-development  in  various  forms 16 

Degenerative  changes  in  vessels,  ganglionic  cells,  or  medullary  substance  not  constituting  true 

sclerosis 15 

Sclerosis  or  atrophy 12 

Diffuse  sclerotic  change 7 

Tuberous  sclerosis     . 6 

No  actual  disease  or  involved  development  of  brain  but  hypertrophy  of  the  skull     ....  6 

Hydrocephalus 5 

Extensive  adhesion  of  membranes  from  old  meningitis  .         .         .         .         .         .         .         .3 

General  cerebral  atrophy 2 

Acute  softening,  recent 2 

Demi  microcephalus          ...............  2 

Brain  above  usual  weight  but  convolutions  large  and  simple 2 

Infantile  hemorrhage 1 

Angiomatous  condition  of  cerebral  vessels  with  degenerative  changes 1 

Glioma  with  sclerosis 1 

Porencephaly  with  non-development 1 

It  will  be  noted  from  this  list  that  no  less  than  31  cases,  or  at  any  rate  25  cases,  were 
not  observed  to  show  any  evidence  of  actual  disease  of  the  brain  or  of  imperfect  develop- 
ment therein.  These  observations  are  probably  the  most  decisive  in  the  literature  upon 
which  to  found  the  idea  that  the  brain  of  a  feeble-minded  person  may  not  show  in  the 


46  SOUTHABD. 

gross  any  evidence  of  defect.  It  is  well  known  that  in  the  field  of  mental  disease  proper, 
commonly  known  as  insanity,  the  opinion  long  prevailed  that  there  was  not  necessarily 
anything  grossly  abnormal  to  be  found  in  the  brains.  Upon  the  older  observations  was 
founded  the  idea  of  the  functional  nature  of  mental  disease  so  long  prevalent.  It  would 
have  been  equally  easy  to  have  founded  a  hypothesis  as  to  the  functional  nature  of  feeble- 
mindedness upon  such  data  as  these  of  Wilmarth.  In  fact,  there  are,  so  far  as  I  know, 
no  more  modern  data  upon  which  to  make  a  new  judgment.  In  the  somewhat  allied 
field  of  epilepsy,  however,  Thorn  and  the  writer  have  recently  discovered  a  somewhat 
similar  percentage  of  normal-looking  brains  if  we  confine  attention  to  the  gross  appear- 
ances; namely,  about  30  per  cent.  Our  own  first  series  to  be  presented  below  (Waverley 
Research  Series  Cases  I-X)  shows  at  least  three  cases  whose  brains  might  well  be  con- 
sidered in  the  gross  as  of  a  normal  appearance.  Perhaps,  then,  the  generalization  which 
Wilmarth's  figures  might  permit  will  attain  objective  value.  Wilmarth  does  not  describe 
further  these  interesting  cases  with  normal-looking  brains.  He  states  that  34  of  the  100 
cases  belong  to  the  school  department  or  were  employed  as  aids  in  the  asylum  department, 
and  that  66  of  the  cases  were  children  belonging  properly  to  the  asylum  department. 

Wilmarth  was  struck  by  the  comparatively  large  number  of  cases  of  actual  cerebral 
disease  in  contrast  with  the  relatively  small  number  with  imperfect  development  which 
seems  to  be  the  causative  agent.  There  were,  however,  16  cases  of  so-called  non-develop- 
ment in  various  forms,  which  put  together  with  two  cases  of  overweight  brain  with  large 
and  simple  convolutions,  a  case  of  porencephaly  with  non-development,  and  possibly 
two  cases  of  demi  microcephalus,  make  a  fairly  large  total  of  cases  of  arrest  of  develop- 
ment. As  against  these  21  cases  of  developmental  arrest  may  be  placed  42  cases;  namely, 
12  cases  of  sclerosis  and  atrophy,  7  of  diffuse  sclerosis,  15  of  degenerative  changes  not 
regarded  as  constituting  sclerosis,  2  of  cerebral  atrophy,  6  of  tuberous  sclerosis.  It  ap- 
pears then  that,  although  it  is  not  safe  to  say  that  there  is  a  relatively  small  number  of 
cases  with  imperfect  development,  there  is  a  somewhat  larger  number  of  cases  of  actual 
sclerosis  of  the  brain  substance  which  may  be  safely  regarded  as  due  in  some  sense  to 
progressive  changes,  or  at  least  to  changes  subsequent  to  birth.  How  many  of  these 
sclerotic  cases  are  merely  complications  of  developmental  arrest  was  of  course  not  possible 
for  Wilmarth  to  decide  and  indeed  constitutes  a  problem  of  the  greatest  difficulty.  Besides 
the  cases  of  arrest  and  the  cases  of  sclerosis  with  or  without  arrest,  there  are  a  few  cases 
of  more  obviously  acquired  nature,  namely,  one  of  infantile  hemorrhage,  three  of  old 
meningitis,  and  two  of  softening  (though  these  latter  may  well  have  been  cases  of  com- 
plication having  nothing  to  do  with  feeble-mindedness). 

The  case  of  angiomatous  condition  of  cerebral  vessels  was  one  of  Mongolian  idiocy. 


WAVERLEY   RESEARCHES.    I. 


47 


Wilmarth  had  five  cases  of  Mongolian  idiocy  in  his  series.  He  regarded  the  brains  as 
"of  good  size  for  imbecile  brains."  The  pons  and  medulla  were  very  small,  weighing 
about  2  ounce  in  each  instance,  whereas  the  usual  weight  according  to  Wilmarth  is  nearly 
twice  as  much.  He  found  the  cerebral  vessels  inclined  to  be  much  thinner  than  in  healthy 
brains,  and  was  led  to  suspect  from  the  defective  nutrition  and  circulation  of  these  chil- 
dren that  the  defective  condition  of  the  vessels  was  a  general  one.  He  laid  down  an 
interesting  hypothesis  in  the  following  words:  "From  the  small  size  of  the  pons  and 
medulla  in  every  instance,  there  seems  to  be  a  strong  probability  that  the  low  nutrition, 
and  possibly  the  other  anatomical  peculiarities  of  this  group,  may  be  due  to  the  imperfect 
development  or  absence  of  certain  cell  groups  in  this  region."  The  following  extracts 
from  Wilmarth's  paper  give  further  notions  as  to  his  conceptions: 

"Probably  the  most  frequent  morbid  condition  met  with  is  sclerosis  in  its  various 
forms.  The  most  destructive  of  these  to  the  functional  activity  of  the  part  involved  is 
the  so-called  sclerose  tuberense.  It  is  usually  seen  on  removing  the  membrane,  as  one  or 
more  areas  of  a  white  color  and  considerably  harder  in  consistence  than  the  surrounding 
tissue,  slightly  elevated  above  the  level  of  the  neighboring  convolutions.  It  may  be 
single  but  is  usually  multiple.  It  seems  to  be  formed  by  a  finely  granular  exudate,  prob- 
ably albuminous  in  character.  If  it  occurs  in  the  motor  regions  of  the  brain,  the  resulting 
paralysis  is  very  complete,  and  if  a  large  portion  of  the  cortex  is  implicated,  profound 
idiocy  is  liable  to  be  the  result." 

"Another  form  of  sclerosis,  in  direct  contrast  with  that  just  described,  is  marked 
by  shrunken  tissue,  the  fibrous  character  of  its  structure,  [sic]  is  more  liable  to  be  found 
in  localized  mass  than  in  disseminated  nodules,  and  is  apparently  less  destructive  to  the 
function  of  the  parts  implicated  unless  it  has  reached  an  advanced  stage." 

"Non-development  is  found  in  several  forms.  A  portion  of  the  cortical  substance 
may  be  thin,  and  instead  of  following  the  typical  arrangement  of  the  fully  developed 
brain,  form  a  number  of  irregular  folds,  which  may  be  so  small  and  numerous  as  to  resem- 
ble a  mass  of  angle  worms.  Again,  the  gyri  may  be  of  a  normal  size  and  appearance, 
but  show  a  diminution  in  number,  or  absence  of  ganglionic  cells  in  certain  layers.  Or, 
again,  the  convolutions  may  begin  of  normal  size  and  development,  but  soon  diminish 
and  sink  beneath  the  surface  of  the  hemisphere,  or  perhaps  entirely  disappear,  before 
acquiring  near  their  normal  length." 

From  the  above  all-too-hasty  analysis  of  the  literature  of  brain  anatomy  in  the  feeble- 
minded, we  may  suggest  the  following  problems  as  facing  us  in  the  present  situation. 

1.  There  should  be  an  attempt  all  over  the  world  to  swell  the  number  of  properly 
reported  cases  of  feeble-mindedness  with  autopsy.     If  we  speak  of  cases  with  suitable 


48  SOtFTHAKD. 

histological  studies  alongside  the  clinical  and  anatomical  observations,  we  shall  shoot 
far  over  the  mark  if  we  concede  that  the  literature  contains  100  comparable  cases  —  cer- 
tainly a  slender  material  from  which  to  draw  conclusions.  Tredgold's  interesting  book, 
for  example,  is  founded  upon  something  like  a  dozen  cases,  among  them  epileptic  and 
juvenile  paretic  cases.  Hammarberg's  work  dealt  with  but  nine  cases.  Many  of  Bourne- 
ville's  cases  are  curiosa. 

2.  Systematic  external  photography  and  photography  of  the  sectional  brain  should 
be  freely  used  and  reproduced.  For  in  no  other  way  can  what  is  normal  in  the  gross 
brain  be  established.  The  "normal"  anatomists  have  little  or  no  opportunity  as  a  rule 
to  lay  down  their  own  standards,  using  as  they  often  do  prison  material,  asylum  material, 
and  the  like,  and  regarding  "brain  anomalies"  with  the  same  equanimity  as  anomalies 
in  the  liver. 

3.  Total  brain  sections  may  facilitate  the  just-mentioned  task  and  are  of  especial 
value  in  marking  off  "secondary"  from  "primary"  aments,  through  evidence  afforded 
of  special  fiber-degenerations. 

4.  What  may  be  called  the  "Mierzejewski  effect"  is  worth  particular  attention, 
viz.  the  problem  afforded  by  certain  cases  of  disharmonious  development  of  gray  and  white 
matter  (gray  in  excess),  in  which  the  commissural  system  is  thought  to  be  deficient.  Rich 
conscious  endowment  with  poor  mobilization  might  result  in  mild  cases,  if  we  carried  the 
Mierzejewski  idea  to  the  limit. 

5.  From  feeble-mindedness  material  we  may  hope  to  establish  the  truth  or  modi- 
fied truth  of  the  idea  attributed  by  Mierzejewski  to  Dejerine,  viz.  that  intellectual  capacity 
depends  more  on  cell  interconnections  than  on  cell  numbers.  The  Dejerine  argument 
is  probably  taken  for  granted  by  most  workers  nowadays  but  certainly  needs  proof  and 
extension  to  details. 

6.  Hammarberg's  idea  that  he  could  more  or  less  approximately  date  the  origin 
of  many  events  of  development  in  his  cases  requires  further  work.  Such  considerations 
as  those  of  Donaldson  re  Laura  Bridgman's  brain  are  decisive  here.  Who  knows  what 
results  bearing  upon  education  would  be  obtained  by  exact  ideas  as  to  the  chronology  of 
normal  cerebral  development?  The  route  to  these  observations  may  in  part  he  through 
feeble-mindedness  material. 

7.  An  exact  definition  in  cerebral  terms  of  "plastic  impotence"  (agenesia)  and 
"plastic  arrest"  (aplasia)  would  help  in  many  fields,  especially  perhaps  in  that  of  de- 
mentia praecox.  Indeed  strong  arguments  could  be  brought  for  the  assertion  that  future 
psychiatry  is  to  be  founded  upon  a  proper  knowledge  of  feeble-mindedness. 

8.  The  problem  of  the  "normal-looking"  brain  in  feeble-mindedness  is  intriguing. 


WAVERLEY   RESEARCHES.    I. 


49 


Is  there  such  a  thing  as  "functional  feeble-mindedness"?  We  speak  of  manic-depressive 
psychosis  perhaps  or  of  certain  psychoneuroses  as  "discords  played  upon  good  instru- 
ments." Can  the  good  instrument  simply  remain  in  its  case,  as  it  were,  with  resulting 
amentia? 

9.  A  host  of  special  problems  in  developmental  mechanics,  glandular  dysfunction, 
disharmonious  development  of  organs,  heterotopia,  dislocation  of  cells,  reactive  gliosis, 
satellitosis,  premature  pigmentation  of  cells,  and  the  like  remain,  not  to  mention  the 
problems  of  alcoholism  and  syphilis  in  parents  and  the  operations  of  heredity  working 
as  it  were  per  se. 


BIBLIOGRAPHY. 

Note:  —  This  bibliography  is  partial.  It  is  based  upon  the  entries  in  the  card  catalogue  of  the 
Massachusetts  School  for  the  Feeble-minded  and  contains  those  titles  which  specifically  refer  to  the  ana- 
tomy of  the  feeble-minded  or  articles  which  are  known  to  contain  anatomical  material  not  indicated  in 
their  titles.  To  this  fundamental  list,  which  is  indicated  by  Roman  numerals  and  Arabic  figures  describ- 
ing the  place  of  articles  in  the  Waverley  collection,  have  been  added  further  references  called  for  by  the 
present  work.  The  bibliography  is  a  working  bibliography  without  pretensions  to  completeness,  and 
has  been  arranged  by  years  in  such  a  manner  that  the  history  of  the  development  of  the  subject  is  clearly 
shown.     Future  additions  to  this  bibliography  will  be  made,  also  by  year  numbers. 

The  word  "Assn."  refers  to  the  Proceedings  of  the  Association  of  Medical  Officers  of  American 
Institutions  for  Idiotic  and  Feeble-minded  Persons. 

1860 

1.    Kind,  C.  F.     De  cranio,  cerebro,  medulla  spinali  et  nervis  in  idiotia  primaria.     Lipsise,  A.  Waldow, 
1860. 

1863 

1.     Bourneville,  D.  M.     Memoire  sur  la  condition  de  la  bouche  chez  les  idiots.     Paris,  Le  Progres 
med.,  (1863),  p.  28. 

1873 

1.  Gairdner.     Athetosis.     1873. 

2.  Bischoff,   T.  L.  W.  von.     Anatomische  beschreibung  eines  mikrocephalen  8  jahrigen  madchens 

Helene  Becker  aus  Offenbach.     1873. 

1876 

1.    Tarbell,  G.  G.    On  the  height,  weight,  and  relative  rate  of  growth  of  normal  and  feeble-minded 
children.     Assn.,  1876,  p.  188. 

1877 

1.  Mierzejewski.     Recherches    anatomo-pathologiques    sur    l'idiotie.     Compte    rendu    du    Congres 

international  de  Geneve,  1877,  p.  642. 

2.  Ireland,  W.  W.     On  Idiocy  and  Imbecility.     London,  1877. 


50  SOUTHARD. 


1878 


1.  Mierzejewski.     Sur  l'anatomie  pathologique  de  l'idiotie.     Compte  rendu  du  Congres  international 

de  medicine  mentale  de  1878,  tenu  a  Paris,  p.  215. 

2.  Heschl.     Ueber  die  vordere  quere  Schlafenwinding.    Festschr.  anlasslich  des  20  jiihrigen  Jubi- 

laeums  der  Irrenanstalt  in  Wien,  1878  (quoted  by  Mierzejewski,  1900). 

1879 

1.  Shuttleworth,  G.  E.     Case  of  microcephalic  imbecility.    Jour.  ment.  sci.,  Oct.,  1878,  vol.  XXIV, 

pp.  438^43,  1  pi. 

2.  Knight,  H.  M.     On  internal  hydrocephalus.     Assn.,  1878-9,  p.  81. 

3.  Mierzejewski,  J.     Researches  in  idiocy.     1879.    Jour.  ment.  sci.,  Jan.,  1879,  n.  s.  vol.  XXIV, 

pp.  562-568. 

4.  Mazier.     Des  arrets  de  developpement  dans  l'idiotie.     Paris,  Emile  Martinet,  1879,  p.  57.     D. 

5.  Chiari.    Ueber  einen  Fall  von  microgyrie  bei  einem  15  monatlichen  Knaben.    Jahrbuch  fiir  kinder- 

heilhunde,   1879. 

1880 

1.  Kerlin,  I.  N.,  and  Mills,  C.  K.  Three  cases  of  progressive  muscular  degeneration.  Phila., 
Collins,  1880,  15  p.,  1  pi.  0.     Reprint  from  Amer.  med.  assoc.  Trans.,  Phila.,  1880,  vol.  XXXI. 

1881 

1.  Bourneville,   D.   M.,   and  Wuillamie.     Idiotie  symptomatique  de  meningo-encephalite.     Re- 

cherches. . .  .sur  l'epilepsie,  1881,  vol.  II,  p.  17. 

2.  Bourneville,  D.  M.,  and  Wuillamie.     Note  sur  deux  cas  d'imbecillite  et  d'idiotie  due  a  la  micro- 

cephalic.    Same,  1881,  vol.  II,  p.  27. 

3.  Bourneville,  D.  M.,  and  Bonnaire.     Sclerose  tubereuse  ou  hypertrophique  des  circonvolutions 

ce're'brales.     Recherches.  . .  .sur  l'epilepsie. . .  .1881,  vol.  II,  p.  3. 

1882 

1.  Bourneville,  D.  M.,  and  Dauge.     Idiotie  symptomatique  d'une  meningo-encephalite  chronique 

generalisee  chez  un  enfant  de  cinq  ans.     Recherches.  . .  .sur  l'epilepsie,  1882,  vol.  Ill,  p.  98. 

2.  Kundrat,  H.     Die  Porencephalic;   eine  anatomische  Studie.     Graz,  1882,  Leuschner  &  Lubensky. 

126  p.    8°. 

1883 

1.  Albrecht,  P.    Sur  le  crane  remarquable  d'une idiote  de21  ans. .  .   Bruxelles,  A.  Manceau,  1883, 

p.  58,  illus.,  plates.     D. 

2.  Shuttleworth,  G.  E.     Physical  features  of  idiocy,  in  relation  to  classification  and  prognosis. 

Liverpool  m.-chir.  jour.,  1883,  vol.  Ill,  pp.  283-3011. 

1884 

1.  Shuttleworth,  G.  E.  The  health  and  physical  development  of  idiots  as  compared  with  mentally 
sound  children  of  the  same  age.  London,  1884,  W.  Clowes  &  Sons,  12  p.,  1  tab.  O.  Assoc. 
. . .  .Proc,  1876-86,  pp.  315-322. 

1885 

1.  Wilmarth,  A.  W.     Notes  on  the  anatomy  of  the  idiot  brain.     Assoc,  1885,  p.  323. 

2.  Dercum,  F.  X.,  and  Reel,  I.  V.     Case  of  arrested  development;   imbecility  with  epilepsy.     State 

hosp.  insane,  Norristown,  Pa.,  Report,  1884-5,  vol.  VI,  p.  88.     Also  Path.  dept. . . .  State 
hosp.  for  the  insane ,  Norristown,  Pa.,  First  an.  report. . . .,  1885,  pp.  28-29. 


WAVERLEY   RESEARCHES.     I.  51 

1886 

1.  Mills,  C.  K.     Arrested  and  aberrant  development  of  fissures  and  gyres  in  the  brains  of  paranoiacs, 

criminals,  idiots,  and  negroes.     Preliminary  study  of  a  Chinese  brain.    Jour.  nerv.  and 
ment.  dis.,  Sept.  and  Oct.,  1886,  vol.  XIII,  nos.  9  and  10.     (Reprint,  37  p.,  2  pi.     D.) 

2.  Dercum,  F.  X.     Brief  synopsis  of  the  various  points  involved  in  the  coarse  examination  of  the 

brain  and  spinal  cord.     Path.  Lab.,  State  Hosp.  for  the  Insane,  Norristown,  Pa.,  1886,  11  p. 

3.  Wilmarth,  A.  W.     Notes  on  the  pathology  of  idiocy.     Assoc,  1886.,  p.  428. 

4.  Bourneville,  D.  M.,  and   Pilliet.     Imbecillite  et  hemiplegie  droite.     Recherches . . . .  sur  l'epi- 

lepsie,  1886,  vol.  VII,  p.  129. 

5.  Bourneville,  D.  M.,  and  Pilliet.     Idiotie  complete  symptomatique  d'une  encephalite  avec  foyers 

de  ramollissement.     Recherches.  . .  .sur  l'epilepsie,  1886,  vol.  VII,  p.  178. 

6.  Bourneville,  D.  M.,  and  Pilliet.     Idiotie  symptomatique  de  sclerose  cerebrale  diffuse.     Re- 

cherches. .  .sur  l'epilepsie,  1886,  vol.  VII,  p.  168. 

1887 

1.  Sachs,  B.     On  arrested  cerebral  development,  with  special  reference  to  its  cortical  pathology.    Jour. 

nerv.  and  ment.  dis.,  Sept.  and  Oct.,  1887,  vol.  XIV,  pp.  541-553.     (Also  same,  Aug.,  1892.) 
(Also  in  N.  Y.  med.  jour.,  May,  1896.) 

2.  Bourneville,  D.  M.,  and  Raoult.     Imbecillite.     Recherches sur  l'epilepsie,  1887,  vol.  VIII, 

p.  207. 

3.  Bourneville,  D.  M.,  and  Sollier,  P.     Des  anomalies  des  organes  genitaux  chez  les  idiots  et  les 

epileptiques.     Recherches.  .  .  .sur  l'epilepsie,  1887,  vol.  VIII,  p.  196. 

4.  Bourneville,  D.  M.,  and  Pilliet.     Deux  cas  d'athetose  double  avec  imbecillite.     Recherches.... 

sur  l'epilepsie. . . .,  1887,  vol.  VIII,  p.  161. 

1888 

1.  Bourneville,  D.  M.     Nouveaux  cas  d'idiotie  avec  cachexie  pachydermique.     Recherches.  . .  .sur 

l'epilepsie,  1888,  vol.  IX,  p.  3. 

2.  Otto.     Casuistische  Beitrage  zur  kenntnis   der  mitrogyrie.     Archiv.  f.  Psychiat.   1,  H.   1,  XX, 

1888-9. 

1889 

1.  Bourneville,  D.  M.     Nouvelle  observation  d'idiotie  myxcedemateuse.     Recherches. . .  .sur  l'epi- 

lepsie, 1889,  vol.  X,  p.  172. 

2.  Osler,  W.     Cerebral  palsies  of  children.     Phila.,  P.  Blakiston,  Son  &  Co.,  1889,  103  pp.,  illus.     D. 

3.  Wulff.     Cerebrale  kinderlahmung  und  geistesschwache.     Zeits.  f.  d.  Behandlung  Schwachsinniger 

u.  Epileptischer,  Dresden,  Oct.,  1889,  vol.  IX,  p.  76. 

4.  Bruce,  A.     On  a  case  of  absence  of  the  corpus  callosum  in  the  human  brain.     Prof.  Roy.  Soc. 

Edinb.  '1887-88)  1889,  xv,  321-341.     12  pi. 

5.  Dunn,  L.  A.     A  case  of  complete  primary  absence  of  the  corpus  callosum.     Guy's  Hosp.  Rep., 

London,  1889,  3d  s.,  xxxi,  117-122.     1  pi. 

1890 

1.  Marchand,   F.     Beschreibung  dreier  mikrocephalen-gehirne.     1890. 

2.  Sachs,  B.,  and  Peterson,  F.     Study  of  cerebral  palsies  of  early  life.     Jour.  nerv.  and  ment.  dis., 

N.  Y.,  May,  1890,  vol.  XVII. 

3.  Wilmarth,  A.  W.     Report  on  the  examination  of  100  brains  of  feeble-minded  children.     Assoc.  . . . 

Proa,  1889  and  1890,  pp.  56-66  (continuous  pp.  138-149). 


52  SOUTHARD. 

4.  Bullard,  W.  N.     Diffuse  cortical  sclerosis  of  the  brain  in  children.     1890. 

5.  Bourneville,  D.  M.     Idiotie  et  epilepsie  symptomatiques.     Recherches. . .  .sur  l'epilepsie,  1890, 

vol.  XI,  p.  21. 

6.  Bourneville,    D.    M.     Idiotie    symptomatique    de    meningo-encephalite.     Recherches ....  sur 

l'epilepsie,  1890,  vol.  XI,  p.  54. 

7.  Bourneville,  D.  M.,  and  Sollier,  P.     Contribution  a  l'e"tude  de  la  porencephalic . . .  .Recherches 

...  .sur  l'epilepsie,  1890,  vol.  XI,  p.  167. 

8.  Bourneville,  D.  M.     Nouvelle  contribution  a  l'etude  de  l'idiotie  myxcedemateuse.     Recherches  — 

sur  l'epilepsie,  1890,  vol.  XI,  p.  206. 

9.  Keller,  Eduard.     Ein  beitrag  zur  pathologischen  anatomie  der  idiotie.     Berlin,  Gustav  Schade 

(Otto  Francke),  1890,  31  pp.     D. 

10.  Starr,  M.  A.     Cerebral  atrophies  of  childhood,  with  special  reference  to  surgical  treatment.    Jour. 

nerv.  and  ment.  dis.,  Nov.,  1890,  pp.  464-470. 

11.  Wildermuth,  H.  A.     Ueber  nahtverknocherung  am  schiideldach  bei  idioten  und  epileptischen. 

Zeits schwach.,  1890,  vol.  X,  p.  81. 

12.  Bourneville,  D.  M.,  and  Camescasse.     Nouvelle  contribution  a  l'etude  de  la  microcephalic 

Recherches.  . .  .sur  l'epilepsie.  .  .  .1890,  vol.  XI,  p.  114. 

13.  Bourneville,  D.  M.,  and  Morax.     Idiotie  symptomatique  d'une  tumeur  cerebrale  (hydroceph- 

alic).    Recherches. . .  .sur  l'epilepsie.  . .  .1890,  vol.  XI,  p.  41. 

14.  Bourneville,  D.  M.,  and  Morax.     Idiotie  symptomatique  de  sclerose  cerebrale  atrophique. 

Recherches.  . .  .sur  l'epilepsie.  . .  .,  1890,  vol.  XI,  p.  33. 

1891 

1.  Bourneville,  D.  M.     Idiotie  myxcedemateuse.     Recherches ....  sur  l'epilepsie,   1891,  vol.  XII, 

p.  34. 

2.  Bourneville,  D.  M.,  and  Raoult.     Idiotie  complete  symptomatique.     Recherches.  . .  .sur  l'epi- 

lepsie, 1891,  vol.  XII,  p.  85. 

3.  Bourneville,  D.  M.,  and  Sollier,  P.     Porencephalic  vrai  unilaterale.     Recherches. . .  .sur  l'epi- 

lepsie, 1891,  vol.  XII,  p.  96. 

4.  Bourneville,  D.  M.     Note  a  propos  de  l'obliteration  des  sutures  du  crane  chez  les  idiots.     Re- 

cherches. .  .  .sur  l'epilepsie,  1891,  vol.  XII,  p.  134. 

5.  Parchappe,  J.-B.  M.  de.     Idiotie.     Bourneville,  D.   M.     Recueil  de  memoires . . . .  sur  l'idiotie. 

1891,  vol.  1,  p.  352. 

6.  Wildermuth,  H.  A.     Ueber  windungsanomalien  am  gehirn  von  epileptischen  und  idioten.     Zeits 

. . .  .schwach.,  Dec,  1891,  vol.  XI,  p.  1. 

7.  Bourneville,  D.  M.,  and  Sollier,  P.     Idiotie  complete  symptomatique  de  sclerose  atrophique 

double  des  circon volutions  motrices. . .  .Recherches. . .  .sur  l'epilepsie. . . .,  1891,  vol.  XII, 
p.  49. 

8.  Arnold,  J.     Gehirn,  riickenmark  und  schadel  eines  hemicephalus  von  dreitagiger  lebensdauer. 

Beitr.  z.  path.  Anat.  u.  a.  allg.  Path.,  Jena,  1891-92,  xi,  407^40,  2  pi. 

1892 

1.  Lloyd,  J.  H.,  and  Willard,  D.     Case  of  porencephalon  in  which  trephining  was  done.     1892. 

2.  Tacquet,  E.     De  l'obliteration  des  sutures  du  crane  chez  les  idiots.     Paris,  1892,  Le  Progres  med., 

72  p.,  illus.     O. 

3.  Barr,  M.  W.     Haematoma  auris.     Assoc,  1892,  p.  293. 

4.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  meningitique.     Recherches ....  sur  l'epilepsie,  1892, 

vol.  XIII,  p.  3. 


WAVERLEY   RESEARCHES.    I.  53 

5.  Bourneville,  D.  M.,  and  Ferrier,  P.     Idiotie  symptomatique  d'un  ancien  foyer  du  lobe  temporal 

gauche.     Recherches ....  sur  l'epilepsie,  1892,  vol.  XIII,  p.  10. 

6.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  meningitique.     Recherches ....  sur  l'epilepsie,  1892, 

vol.  XIII,  p.  66. 

7.  Bourneville,  D.  M.,  and  Dauriac.     Idiotie  complete  symptomatique  de  double  porencephalic 

vrai.     Recherches.  .  .sur  l'epilepsie,  1892,  vol.  XIII,  p.  89. 

8.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  meningitique.     Recherches sur  l'epilepsie,  1892, 

vol.  XIII,  p.  164. 

9.  Bourneville,  D.  M.,  and  Ferrier,  P.     Idiotie  meningitique.     Recherches sur  l'epilepsie, 

1892,  vol.  XIII,  p.  172. 

10.  Bourneville,  D.  M.,  and  Ferrier,  P.     Idiotie  complete.     Recherches. ..  .sur  l'epilepsie,  1892, 

vol.  XIII,  p.  201. 

11.  Bourneville,    D.    M.,    and    Dauriac.     Idiotie    meningitique.     Recherches ....  sur    l'epilepsie, 

1892,  vol.  XIII,  p.  207. 

12.  Bourneville,  D.  M.,  and  Ferrier,  P.     Idiotie  symptomatique.     Recherches ....  sur  l'epilepsie, 

1892,  vol.  XIII,  p.  232. 

13.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  congenitale.     Recherches sur  l'epilepsie,  1892, 

vol.  XIII,  p.  256. 

14.  Bourneville,  D.  M.,  and  Dauriac.     Imbecillite  et  hemiplegie  droite  avec  athe"tose.     Recherches 

...  .sur  l'epilepsie,  1892,  vol.  XIII,  p.  38. 

15.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  microcephalique.     Recherches. . .  .sur  l'epilepsie. . . ., 

1892,  vol.  XIII,  p.  23. 

16.  Bourneville,  D.  M.,  and  Ferrier,  P.     Idiotie  complete  symptomatique  de  sclerose  atrophique. 

Recherches.  .  .  .sur  l'epilepsie,  1892,  vol.  XIII,  p.  56. 

17.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  symptomatique  de  sclerose  atrophique  de  l'hemisphere 

cerebral  gauche  et  de  meningo-encephalite  de  l'hemisphere  droit.     Recherches ....  sur  l'epi- 
lepsie, 1892,  vol.  XIII,  p.  132. 

18.  Bourneville,  D.  M.,  and  Dauriac.     Idiotie  symptomatique  de  sclerose  atrophique.     Recherches 

...  .sur  l'epilepsie,  1892,  vol.  XIII,  p.  216. 

19.  Bourneville,  D.  M.,  and  Noir,  J.      Idiotie  symptomatique  de  sclerose  cerebrale  atrophique. 

Recherches. . .  .sur  l'epilepsie,  1892,  vol.  XIII,  p.  223. 

1893 

1.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  congenitale;    atrophie  cerebrale.     Arch,  de  neurol., 

1893,  vol.  XXV,  pp.  228-251;  also  Recherches. . .  .sur  l'epilepsie,  1892,  vol.  XIII,  pp.  256- 
282. 

2.  Berkhan,  O.     Eigentiimliche  mit  einschlafen  verbundene  anfalle.      Zeits.  schwach.,  1893,  pp.  13, 

44,  64. 

3.  Bourneville,  D.  M.,  and  Paul-Boncour,  G.     Imbecillite.     Recherches ....  sur  l'epilepsie,  1893, 

vol.  XIV,  p.  91. 

4.  Bourneville,  D.  M.,  and  Sollier,  P.     Idiotie  et  epilepsie  symptomatiques.     Recherches. . .  .sur 

l'epilepsie,  vol.  XIV,  p.  164. 

5.  Bourneville,  D.  M.,and  Noir,  J.     De  quelques  formes  de  l'hydrocephalie.     Recherches. ..  .sur 

l'epilepsie,  1893,  vol.  XIV,  p.  175. 

6.  Matell.     Ein  fall  von  heterotopic  der  grauen  substanz.     Archiv.  f.  Psychiat,  pt.  1,  XXV,  1893. 

1894 
1.     Barr,  M.  W.     Inchoative  paranoia.     Assoc,  1894,  p.  406. 


54  SOUTHARD. 

2.  Bourneville,  D.  M.,  and  Noir,  J.     Idiotie  complete  congenitale.     Recherches ....  sur  l'epilepsie 

....,  1894,  vol.  XV,  p.  81. 

3.  Sollier,  P.     L'idiotie  et  Timbeeillite  au  point  de  vue  nosographique.     Paris,  Le  Progres  med., 

1894,  p.  6.     O.     Archives  d.  neurol.,  Jan.,  1894,  vol.  XXVII,  pp.  33-38. 

4.  Bourneville,  D.  M.     Contribution  a  l'etude  de  la  microcephalic.     Cong.  d.  med.  alien,  et.  neurol. 

de  France,  Proc.-verb.,  1894,  vol.  V,  pp.  526-587,  8  pi. 

5.  Porter,  W.  T.     The  growth  of  St.  Louis  children.     Trans,  of  the  Acad,  of  Sc.  of  St.  Louis,  1894, 

vol.  VI,  No.  12. 

1895 

1.  Pearce,  F.  S.     Causes  conspiring  to  produce  mental  enfeeblement  in  children.     Abstr.  Rev.  of 

med.,  Oct.,  1895,  pp.  716-718. 

2.  Pearce,  F.  S.     Causes  conspiring  to  produce  mental  enfeeblement  in  children.     Amer.  medico- 

surgical  bulletin,  Aug.  1,  1895,  pp.  9-14. 

3.  Humphrey,  Sir  G.     Notes  on  the  microcephalic  or  idiot  skull,  and  on  the  macrocephalic  or  hydro- 

cephalic skull.     Jour.  anat.  and  physiol.,  Jan.,  1895,  vol.  XXIX,  pp.  304-328. 

4.  Hammarberg,  C.     Studien  iiber  klinik  und  pathologie  der  idiotie. ..  .Upsala,  1895,  E.  Berling, 

126  p.,  plates.     O.     Leipzig,  K.  F.  Kohler,  1895,  126  p.,  pi. 

5.  Bourneville,  D.  M.     Trois  cas  d'idiotie  myxcedemateuse.     Recherches ....  sur  l'epilepsie,  1895, 

vol.  XVI,  p.  167. 

6.  Bourneville,  D.  M.     Sclerose  cerebrale  hypertrophique  ou  tubereuse  compliquee  de  meningite. 

Recherches. . .  .sur  l'epilepsie. . .  .,  1895,  vol.  XVI,  p.  98. 

7.  Bourneville,  D.  M.,  Lombard,  and  Pilliet.     Idiotie  complete  symptomatique;    microcephalic 

congenitale.  .  .   Recherches.  .  .  .sur  l'epilepsie. . . .,  1895,  vol.  XVI,  p.  113. 

8.  Oppenheim.     Ueber  Microgyrie.     Neurol  Centralbl.,  1895. 

1896 

1.  Ireland,  W.  W.     Observations  on  mental  affections  in  children  and  allied  neuroses.     Edinb.  med. 

jour.,  1895-6,  vol.  XLI,  p.  710,  etc.     (Continued  article.) 

2.  Bourneville,   D.   M.     Six  cas  d'idiotie  myxcedemateuse.     Recherches. ..  .sur  l'epilepsie,   1896, 

vol.  XVII,  p.  134. 

3.  Bourneville,  D.  M.     Idiotie  myxcedemateuse.     Recherches ....  sur  l'epilepsie,  1896,  vol.  XVII, 

p.  144. 

4.  Bourneville,  D.  M.     De  Taction  de  la  glande  thyroide  sur  la  croissance  et  l'obe'site'  chez  les  idiots 

myxcedemateuse.     Recherches. .  .  .sur  l'epilepsie,  1896,  vol.  XVII,  p.  195. 

5.  Gundel,  A.     Zur  klassifizierung  der  idioten.     Zeits.  f.  d.  Behand.  Schwachsin.  i.  Epilep.,  Dresden, 

Sept.,  1896,  vol.  XVI,  p.  73. 

6.  Bourneville,  D.  M.     Sclerose  cerebrale  hemispherique;    idiotie,  he'miple'gie  droite  et  epilepsie 

consecutives.     Recherches ....  sur  l'epilepsie .  . .  . ,  1896,  vol.  XVII,  p.  82. 

7.  Bourneville,  D.  M.     Alcoolisme;  hemiplegie  gauche  et  epilepsie  consecutives;  sclerose  atrophique; 

pachymeningite    et    meningo-encephalite.     Recherches ....  sur    l'epilepsie ,    1896,    vol. 

XVII,  p.  207.     (Continued.) 

8.  Sachs,  B.     A  family  form  of  idiocy,  generally  fatal,  associated  with  early  blindness  (amaurotic 

family  idiocy).    J.  Nerv.  &  Ment.  Dis.,  New  York,  1896,  n.  s.,  xxi,  475-479. 

1897 

1.     Bourneville,  D.  M.,  and  Dardel.     Idiotie  et  Epilepsie  symptomatiques  de  sclerose  atrophique 
des  deux  lobes  frontaux.     Recherches sur  l'epilepsie ,  1897,  vol.  XVIII,  p.  96. 


WAVERLEY    RESEARCHES.     I. 


55 


2.  Bourneville,  D.  M.  Alcoolisme;  hemiplegie  gauche  et  epilepsie  consecutives;  sclerose  atrophique; 
pachymeningite  et  meningo-encephalite.  Recherches ....  sur  l'epilepsie,  1897,  vol.  XVIII, 
p.  83.     (Concluded.) 

1898 

1.  Sachs,  B.     Die  amaurotische  familiare  Idiotic     Deutsche  med.  Wchnschr.,  Leipzig  u.  Berlin,  1898, 

xxiv,  63-69. 

2.  Spiller,  W.  G.     Contribution  to  the  study  of  secondary  degeneration  following  cerebral  lesions. 

Jour.  nerv.  and  ment.  dis.,  Jan.,  1898,  vol.  XXV,  pp.  1-19. 

3.  Sailer,  J.     Hypertrophic  nodular  gliosis.     Jour.  nerv.  and  ment.  dis.,  June,  1898,  vol.  XXV,  pp. 

405-440. 

4.  Barr,  M.  W.     Some  diseases  common  to  the  feeble-minded.     Jour,  psycho-asthenics,  Dec,  1898, 

p.  89. 

5.  Telford-Smith,  T.     Paralytic  type  of  idiocy  and  imbecility.     Pediatrics,  1898,  vol.  V,  pp.  541-549. 

6.  Bourneville,  D.  M.,  and  Chapotin.     Athetose  double  avec  mouvements  convulsifs  chroniques 

de  la  face  simulant,  les  tics  convulsifs.     Recherches.  .  .  .  sur  l'epilepsie .  .  .  .,  1898,  vol.  XIX, 
p.  26. 

7.  Berkhan,  O.     Zur  entwickelung  und  deutung  der  sogenannten  Azteken-mikrocephalen.     Zeits .... 

schwach. . .   April,  1898,  vol.  XVIII,  p.  33. 

8.  Bourneville,  D.  M.     Idiotie  symptomatique  de  sclerose  tubereuse  ou  hypertrophique.     Re- 

cherches ....  sur  l'epilepsie .....  1898,  vol.  XIX,  p.  183. 

9.  Hrdlicka,  A.  F.     Anthropological  studies.    Jour,  psycho-asthenics,  Dec,  1898,  vol.  Ill,  p.  47. 

(Continued.) 

10.  Ireland,  W.  W.    The  mental  affections  of  children,  idiocy,  imbecility  and  insanity.     London, 

1898. 

11.  Meine.     Ein  beitrag  sur  lehre  von  der  echten  heterotopic  graun  hirnsubstanz.     Archiv.  f.  psychiat., 

XXX,  2  Heft,  1898. 

12.  Scarpatetti.     Microcephalia  vera.  ibid. 

13.  Bresler.     Klinische  und  pathologisch-anatomische  beitrage  sur  microgyrie.    ibid. 

14.  Monakow.     Ueber  einen  fall  von  mikrocephalia,  ibid.,  XXXI,  s.  845. 

15.  Strumpell,  A.     Ueber  die   Westphal'sche  pseudosklerose   and  iiber   diffuse  hirnsklerose,  insbe- 

sondere  bei  kindern.     Deutsche  Ztschr.  f.  Nervenh.,  Leipzig,  1898,  xii,  115-149. 

1899 

1.  Barr.,  M.  W.    The  how,  the  why,  and  the  wherefore  of  the  training  of  feeble-minded  children. 

Jour,  psycho-asthenics,  Sept.,  1899,  p.  204. 

2.  Barr,  M.  W.     Adenoma  sebaceum.     Jour,  psycho-asthenics,  March,  1899,  p.  137. 

3.  Collier,  J.  S.     Cerebral  diplegia.     Brain,  part  LXXXVII,  Autumn,  1899. 

4.  Kannegiesser,  E.     Der  schadliche  einfluss  behinderter  nasenatmung  auf  die  korperliche  und  geistige 

entwickelung  der  kinder.     Zeits. . .  .schwach. . .  .Sept.,  1899,  vol.  XIX,  p.  161. 

5.  Hrdlicka,  A.  F.     Anthropological  studies.    Jour,  psycho-asthenics,  (Dec,  1898,  vol.  Ill,  p.  47), 

March,  1899,  vol.  Ill,  p.  99;  June,  1899,  vol.  Ill,  p.  153.     (Concluded.) 

6.  Wylie,  A.  R.  T.     Contribution  to  the  study  of  the  growth  of  the  feeble-minded  in  height  and  weight. 

Faribault,  Minn.,  1901,  7  p.,  pi.,  tables.     O. 

7.  Bourneville,  D.  M.     Idiotie  et  epilepsie  symptomatique  de  sclerose  tubereuse  ou  hypertrophique. 

Recherches ....  sur  l'epilepsie . . . . ,  1899,  vol.  XX,  p.  183. 

8.  Bourneville,  D.  M.     Inegalite  de  poids  des  hemispheres  cere"braux  et  cerebelleux.     Recherches .... 

sur  l'epilepsie,  1899,  vol.  XX,  p.  107.     (Continued.) 


56  SOUTHARD. 


1900 


1.  Bourneville,  D.  M.     Inegalite  de  poids  des  hemispheres  cerebraux  et  cere"belleux.     Recherches 

. . .  .sur  l'epilepsie. . . .,  (1899,  vol.  XX,  p.  107);   1900,  vol.  XXI,  p.  130.     (Concluded.) 

2.  Bourneville,  D.  M.    Thymus  et  glands  thyroide  chez  les  enfants  anormaux.     Recherches .... 

sur  l'epilepsie . . . . ,  vol.  XXI,  p.  123.     (Continued.) 

3.  Bourneville,  D.  M.     Statistique  sur  la  persistance  ou  l'absence  du  thymus  chez  les  enfants  anor- 

maux.    Recherches. . .  .sur  l'epilepsie. . . .,  1900,  vol.  XXI,  p.  126.     (Continued.) 

4.  Bourneville,  D.  M.     Statistique  sur  la  persistance  de  la  suture  metopique.     Recherches. . .  .sur 

l'epilepsie,....  1900,  vol.  XXI,  p.  202. 

5.  Bourneville,  D.  M.     Essai  de  classification  anatomo-pathologique  de  l'idiotie.     Recherches .... 

sur  l'epilepsie,  1890,  vol.  XI,  p.  112. 

6.  Bourneville,  D.  M.     Nouvelle  contribution  a  l'etude  de  la  microcephalic ....  Recherches .... 

sur  l'epilepsie,  1900,  vol.  XXI,  p.  182. 

7.  Bourneville,  D.  M.,  and  Oberthur.     Idiotie  microcephalique; agenesie  cerebrate;  cerveau 

pseudo-kystique.     Recherches.  .  .  .sur  l'epilepsie,.  .  .  .1900,  vol.  XXI,  p.  81. 

8.  Mierzejewski.     De  l'anatomie  pathologique  de  l'idiotie  XIII  Congres  international  de  medicine, 

Paris,  1900.     Section  de  Psychiatrie.  torn.  8,  p.  148. 

9.  Shuttleworth  and  Fletcher-Beach.     Idem,  ibid.,  p.  154. 

10.  Bourneville.    Idem,  ibid.,  p.  167. 

11.  Philippe  and  Oberthur.     Contribution  a  l'etude  de  l'histologie  pathologique  de  l'idiotie.     Ibid., 

p.  207. 

1901 

1.  Christopher,  W.  S.     Diagnosis  of  the  backward  child.     Child  study  monthly  and  jour,  of  adol., 

May,  1901,  vol.  VII,  pp.  417-429. 

2.  Bancroft,  M.     Classification  of  the  mentally  deficient.     N.  C.  C.  &  C,  Proa,  1901,  p.  191. 

1902 

1.  Patrick.     Hereditary  cerebellar  ataxia.    Jour.  nerv.  and  ment.  dis.,  Mar.,  1902,  vol.  29,  pp  129- 

152. 

2.  Berkhan.     Ueber  einige  besondere  gruppen  unter  den  idioten.     Zeits ....  schwach May,  1902, 

vol.  XXII,  p.  65. 

3.  Ballantyne.     Antenatal  pathology  and  hygiene.     London,  1902,  1904. 

1903 

1.  Bourneville,  D.  M.     Statistique  sur  la  persistance  ou  l'absence  du  thymus  chez  les  enfants  anor- 

maux.    Recherches. . .  .sur  l'epilepsie,. . .  .1903,  vol.  XXIV,  p.  269. 

2.  Tredgold,  A.  F.     Mott's  Archives  of  Neurology  and  Psychiatry,  1903. 

3.  Bolton,  J.  S.     On  the  Histological  Basis  of  Amentia  and  Dementia.     Ibid. 

1904 

1.  Bourneville,  D.  M.    Thymus  et  glande  thyroide  chez  les  enfante  anormaux.    Recherches 

sur  l'epilepsie,. . .  .1904,  vol.  XXV,  p.  62.     (Continued.) 

2.  Bourneville,  D.  M.     Statistique  sur  la  persistance  ou  l'absence  du  thymus  chez  les  enfants  anor- 

maux.    Recherches ....  sur  l'epilepsie ,  1904,  vol.  XXV,  p.  58.     (Concluded.) 

3.  Bourneville,  D.  M.     Statistique  sur  la  persistance  de  la  suture  metopique.     Recherches 

sur  l'epilepsie,. . . .  1904,  vol.  XXV,  p.  53.     (Continued.) 

4.  U.  S.  Bureau  of  Education.     Statistics  of  growth.     1904. 


WAVERLEY  RESEARCHES.    I.  57 

1905 

1.  Bourneville,  D.  M.     Thymus  et  glande  thyro'ide  chez  les  enfants  anormaux.     Recherches . . . . 

sur  l'epilepsie, 1905,  vol.  XXVI,  p.  140.     (Continued.) 

2.  Bourneville,  D.  M.     Statistique  sur  la  persistance  de  la  suture  metopique.     Recherches .... 

sur  l'epilepsie,. . . .  1905,  vol.  XXVI,  p.  133.     (Concluded.) 

1906 

1.    Bourneville,  D.  M.     Thymus  et  glande  thyroide  chez  les  enfants  anormaux.     Recherches. . . . 
sur  l'epilepsie, ....  1906,  vol.  XXVII,  p.  60.     (Concluded.) 

1907 

1.  Clark,  L.  P.,  and  Atwood,  C.  E.     Longevity  of  idiots.     Med.  rec,  Aug.  31,  1907. 

2.  Mott,  Frederick  W.    Two  cases  of  amaurotic  dementia  (idiocy)  and  a  correlation  of  the  micro- 

scopic changes  in  the  central  nervous  system,  with  the  results  of  a  chemical  analysis  of  the 
brains.     Neurol.  Path.  Lab.  Lond.  County  Asyl.,  Claybury,  London,  1907,  iii,  218-245,  4  pi. 

1908 

1.    Orton,  S.  T.     Pathological  study  of  a  case  of  hydrocephalus.     Amer.  Jour.  Insan.,  Oct.,  1908,  vol. 
LXV,  p.  229. 

1909 

1.     Arnold,  E.  H.     Deformities  of  feeble-minded  children.     Yale  med.  jour.,  Feb.,  1909,  vol.  XV, 
pp.  281-295. 

1910 

1.  Sachs,  B.     Amaurotic  family  idiocy  (Tay-Sachs  Disease).     In:  Mod.  Med.  (Osier  &  McCrae). 

2d  ed.     Philadelphia,  and  New  York,  1910,  v.  863-870. 

2.  Shuttleworth,  G.   E.   and  Fletcher-Beach.     Revised  by    G.   E.   Shuttleworth.     Idiocy  and 

Imbecility.     In:  Syst.  Med.  (Allbutt  &  Rolleston).     8°.     London,  1910,  viii,  874-891. 

1911 

1.  Bullard,  W.  N.    Mongolian  idiocy.    Boston  med.  and  surg.  jour.,  Jan.  12,  1911,  vol.  CLXIV, 

pp.  56-57,  plates. 

2.  Dean,  H.  R.    Idiocy  and  congenital  syphilis.    Brit.  Jour.  Child  Dis.,  1912,  X,  p.  385. 

1912 

1.  Goddard,  H.  H.     Height  and  weight  of  feeble-minded  children  in  American  institutions.    Jour. 

nerv.  and  ment.  dis.,  April,  1912,  vol.  XXXfX,  pp.  217-235,  charts. 

2.  Vogt,  H.     Die  angeborenen  defekte  und  entwickelungsstorungen  des  gehims.     Handb.  d.  Neurol. 

(Lewandowsky).     Berlin,  1912,  ii,  1-28. 

1913 

1.  Clark,  L.  P.,  and  Stowell,  W.  L.     Study  of  mortality  in  four  thousand  feeble-minded  and  idiots. 

N.  Y.  med.  jour.,  Feb.  22,  1913,  pp.  376-378. 

2.  Black,  D.  D.     The  central  nervous  system  in  a  case  of  cyclopia  in  homo.    J.  Comp.  Neurol. 

Philadelphia,  1913,  xxiii,  193-257. 

3.  Black,  D.  D.    The  study  of  an  atypical  cerebral  cortex.    J.  Comp.  Neurol.  Philadelphia,  1913, 

xxiii,  351-369. 


58 


SOUTHARD. 


4.  Reuben,  M.  S.,  and  Cleaver,  E.  E.    Oxycephaly.     Arch.  Pediatr.,  New  York,  1913,  xxx,  820-824. 

5.  Coriat,  I.  H.     Amaurotic  family  idiocy.     Arch.  Pediatr.     New  York,  1913,  xxx,  404-415. 

1914 

1.  Batten,  F.  E.    Family  cerebral  degeneration  with  macular  change  (so-called  juvenile  form  of 

family  amaurotic  idiocy).     Quart.  J.  M.,  Oxford,  1914,  vii,  444-454. 

2.  Hume,  W.  E.     A  case  of  amaurotic  family  idiocy.     Rev.  Neurol.  &  Psychiat.,  Edinburgh,  1914, 

xii,  281-287.    4  pi. 

3.  Ziehen,  T.    Zur  aetiologie  und  auffassung   des   soganannten   moralischen  schwachsinns.    Wien. 

med.  Wchnschr.,  1914,  Ixiv,  2242-2245. 

4.  Tredgold,  A.  F.    Mental  Deficiency.     Second  Edition,  London,  1914. 

5.  Bolton,  J.  S.     On  the  Brain  in  Health  and  Disease.    London,  1914. 

6.  Peters.     A  microcephalic  idiot  with  malformation  of  brain.    Jour.  A.  M.  A.,  lxiii,  p.  536. 

7.  Mott,  F.  W.     Nature  and  nurture  in  mental  development.     London,  1914,  J.  Murray.     163  p.     8°. 

1915 

1.  Davenport,  C.  B.    The  feebly  inhibited.     II.     Nomadism  or  the  wandering  impulse,  with  special 

reference  to  heredity.     Proc.  Nat'l  Acad.  Sc,  Washington,  1915,  i,  120. 

2.  Pearson,  Karl.     Mendelism  and  the  problem  of  mental  defect.     III.     On  the  graduated  character 

of  mental  defect  and  on  the  need  for  standardizing  judgments  as  to  the  grade  of  social  in- 
»  sufficiency  which  shall  involve  segregation.     (New  York),  1915  (G.  E.  Stechert).     51  p. 

3.  Weygandt,  W.     Idiotie  und  Imbezileitat.     In:  Handb.  d.  Psychiat.  (Aschaffenburg).    Leipzig  und 

Wien,  1915,  95-311.    4°. 

4.  Southard,  E.  E.     On  the  value  of  the  feeble-minded  as  subjects  of  research  in  efficiency.    Proc. 

Nat.  Conference  of  Charities  and  Correction,  1915. 


II. 


CLINICAL,  ANATOMICAL,  AND  BRIEF  HISTOLOGICAL  DESCRIPTION  OF 

TEN  CASES  OF  FEEBLE-MINDEDNESS,  WITH  EIGHTY-FOUR  PLATES 

(WAVERLEY  RESEARCH  SERIES,  CASES  I-X). 

E.  E.  Southard  and  Annie  E.  Taft. 


II. 


CLINICAL,  ANATOMICAL,  AND  BRIEF  HISTOLOGICAL  DESCRIPTION  OF 
TEN  CASES  OF  FEEBLE-MINDEDNESS. 

With  Eighty-four  Plates  (Waverley  Research  Series,  Cases  I-X). 
E.  E.  Southard  and  Annie  E.  Taft. 

We  proceed  to  a  condensed  description  of  the  findings  in  Cases  I-X  of  the  Waverley 
Research  Series.  For  convenience  we  offer  the  following  table,  showing  a  number  of  facts 
about  each  case,  chiefly  of  a  catalogue  nature: 


Clini- 

Research 

cal 

Local 

Harvard 

Photo- 

Assigned 

Height 

Brain 

Series 

Source 

Autopsy 

Series 

graph 

Actual 

Mental 

last 

Weight. 

Brief 

number 

number 

number 

number 

number 

Sex 

Age 

Age 

taken 

grams 

designation 

i 

W.  2268 

Taylor,  65 

14.5 

28 

M 

5 

1— app. 

82 

400? 

Microcephaly 

ii 

W.  1437 

Taylor,  21 

14.6 

26 

M 

20.5 

1— app. 

subn. 

620 

« 

in 

D.  14550 

D. 1279 

12.20 

24 

M 

45 

7    app. 

126 

610 

it 

IV 

D. 16282 

D.  1517 

12.21 

23 

F 

62 

12=*=  app. 

143 

1340 

Moron  or 
subnormal 

V 

D. 14779 

D.  1413 

13.13 

1413 

M 

16 

12=*=  app. 

168 

1435 

Subnormal, 
dementia 
praecox 

VI 

W.  1453 

Canavan,  3 

13.47 

75 

M 

26 

2  Binet 

158 

1130 

Idiot 

VII 

W.  1574, 
1618 

Canavan,  8 

14.13 

78 

F° 

25 

5(2-  )3 
Binet 

146 

1270 

Imbecile 

VIII 

Magrath,  3917 

12.22 

1 

M 

36 

12  ±  app. 

179 

1340 

Murderer 

IX 

W.  808  Bur- 
bank  9760 

S.B.I.  14.22 

14.69 

14.69 

M 

39 

7  Binet 

178 

1620 

Imbecile 

X 

W.  971 

S.B.I.  14.69 

15.2 

15.2 

II 

37 

2.4  Binet 

144 

1450 

Imbecile 

W.  =  Waverley  (Massachusetts  School  for  Feeble-minded).  Burbank  =  Burbank  Hospital,  Fitchburg.  Cana- 
van =  private  autopsy  series,  M.  M.  Canavan.  D.  =  Danvers  State  Hospital.  Magrath  =  Medical  Examiner's 
series,  G.  B.  Magrath.  S.B.I.  =  series  since  establishment  of  Massachusetts  State  Board  of  Insanity,  Pathological 
Service,  July  1,  1914.     Taylor  =  private  autopsy  series,  E.  W.  Taylor. 

The  items  of  our  description  call  for  little  comment.     They  are  in  general: 

a.  Clinical  Findings 

b.  Autopsy  Findings 

c.  Special  Description  of  Brain 

d.  Partial  Microscopic  Description 

e.  Anatomical  and  Histological  Summary. 

As  to  a.  Clinical  Findings:  These  have  been  arranged  so  far  as  possible  to  follow  a 
scheme  employed  at  the  Massachusetts  School  for  the  Feeble-minded  and  originated  by 
Dr.  W.  E.  Fernald.     The  headings  are  ten  in  number,  as  follows: 


62  SOUTHARD  AND  TAFT. 

1.  Physical  Examination. 

2.  Family  History. 

3.  Personal  and  Developmental  History. 

4.  History  of  School  Progress. 

5.  School  Examinations. 

6.  Practical  Knowledge. 

7.  Economic  Efficiency. 

8.  Social  History  and  Reactions. 

9.  Moral  Reactions. 
10.  Psychological  Tests. 

Following  the  items  thus  arranged  are  notes,  usually  brief,  concerning  the  institutional 
history,  if  any,  of  the  patient. 

As  to  b.  Autopsy  Findings:  These  are  limited  to  the  gross  anatomical  findings  of  the 
examiner  as  made  on  the  autopsy  table.  Their  results  are  more  systematically  given  in 
table  form  in  Article  III. 

As  to  c.  Special  Description  of  Brain:  The  data  are  founded  upon  examination,  as  a 
rule,  subsequent  to  the  autopsy  and  to  the  preservation  of  the  brain,  which  has  been  in  all 
cases  in  10%  formaldehyde  solution,  in  many  cases  for  relatively  long  periods,  which  are  obvi- 
ous from  the  dates  included  in  the  descriptions.  As  a  rule,  the  special  brain  description  has 
had  the  advantage  of  comparison  of  the  brain  specimen  itself  with  the  photographs, 
systematically  taken,  of  the  brain  before  and  after  stripping  the  pia  mater.  These  descrip- 
tions are  largely  the  product  of  Dr.  Taft,  who  has  personally  stripped  each  brain  of  the  pia 
mater,  preserving  the  pia  mater  in  certain  cases  where  there  was  question  of  important 
lesion  therein.  The  nomenclature  is,  as  a  rule,  self-explanatory  and  follows  largely  the 
nomenclature  of  Quain's  Anatomy. 

As  to  d.  Partial  Microscopic  Examination:  It  must  be  insisted  that  this  is  really  but 
partial  and  has  no  pretensions  to  the  completeness  which  the  resources  of  a  modern  labora- 
tory will  eventually  command.  Nevertheless,  we  have  resorted  in  each  instance  to  total 
brain  sections  stained  by  the  Weigert  myelin  sheath  method  in  our  estimates  of  the  fibre 
content  of  the  brain.  The  resulting  estimate  is,  as  a  rule,  entirely  qualitative.  But  it  may 
be  questioned  whether  it  is  possible  at  this  time  to  make  more  than  a  qualitative  estimate 
of  fibre  contents.  The  total  brain  sections  stained  by  the  Weigert  method  have  been  of 
value  in  the  estimates  of  the  depth  of  the  corpus  callosum,  as  well  as  for  the  purpose  of 
discovering  special  periods  of  degeneration  or  faulty  development  of  fibre  systems. 

We  have,  also,  employed  staining  methods  for  the  study  of  cortical  architecture, 


WAVERLEY   RESEARCHES.    II.  63 

employing  as  a  rule  cresyl- violet  in  place  of  thionin  and  methylen  blue.  This  sharp  nuclear 
stain  has  permitted  us  in  most  cases  to  make  a  profitable  study  of  the  cortical  lamination, 
as  well  as  to  bring  out  the  exudate  about  vessels  where  exudate  is  present.  As  will  be 
emphasized  in  Article  III,  the  existence  of  exudate  in  more  cases  than  had  been  at  first 
suspected  is  probably  of  importance  from  the  genetic  standpoint,  since  syphilis  or.  some 
kindred  chronic  inflammatory  condition  may  be  suspected  in  cases  with  such  exudate. 
Again,  we  have  been  able  to  observe  rod  cells  in  certain  cases,  which  cells  again  tend  to 
indicate  a  more  progressive  condition  than  has  been  considered  typical  in  cases  of  feeble- 
mindedness. In  suitable  cases,  we  intend  to  make  special  topographical  studies  of  cortical 
laminations.  This  we  have  in  hand  in  chosen  instances,  and  the  resulting  descriptions 
are  intended  to  appear  in  later  articles  in  this  series.  For  the  present,  as  will  be  evident 
from  Article  III,  we  have  limited  our  microscopy  to  the  question  of  exudate,  rod  cells,  and 
the  like,  on  the  one  hand,  and  to  qualitative  estimates  of  cortex  lamination,  fibre  content, 
on  the  other. 

As  to  e.  Anatomical  and  Histological  Summary:  We  have  attempted  to  bring  out  the 
main  structural  points  in  each  case,  with,  however,  little  or  no  attention  to  the  total  genetic 
picture  presented  by  the  case.     This  total  genetic  picture  is  reserved  for  Article  III. 

Further  light  upon  the  anatomical  situation  presented  by  each  brain  is  offered  in  the 
description  of  the  plates.  The  most  inclusive  view  of  each  case  from  all  available  aspects : 
clinical,  anatomical,  histological,  and  genetic,  together  with  points  especially  mentioned 
in  the  description  of  the  plates,  is  given  in  Article  III. 


Synopsis  op  Findings  of  Case  I. 

a)  Clinical. 

1.  Physical  Examination. —  P.  Cap.  was  born  June  19,  1897,  and  upon  admission,  at  five  years 
of  age,  was  32  inches  tall  and  weighed  16  pounds.  A  photograph  shows  typical  microcephaly,  with  a  head 
roughly  diamond-shaped  when  viewed  from  the  side,  with  large  ears;  spinal  caries  of  the  dorsal  region, 
with  anterolateral  curvature;  thighs  sharply  flexed  on  abdomen,  and  legs  flexed  on  thighs;  arms  slightly 
flexed  and  in  position  of  contracture  at  elbows ;  strabismus.  The  eyes  are  described  as  "  rather  intelligent 
looking"  despite  the  patient's  inability  to  understand  things  said.  Patient  would  turn  head  when 
spoken  to,  and  follow  persons  or  bright  objects  with  his  eyes.  Spastic  crural  paraplegia;  slight  ability 
to  move  hands  and  arms,  and  ability  to  grasp  small  objects  with  the  hands.  Although  unable  to  walk, 
the  patient  was  able  to  push  himself  along  the  floor,  and  would  come  at  command.  Would  stop  crying 
when  he  heard  food  being  brought  in  the  customary  way.  Absence  of  control  over  bladder  or  rectum; 
daily  vomiting.  Patient  is  described  as  having  had  measles,  and  is  said  to  have  been  able  to  kick  up  his 
legs  at  some  time  prior  to  his  entrance  to  the  school;   but  it  is  possible  that  this  reaction,  described  by 


64  SOUTHARD   AND  TAFT. 

the  parents,  was  merely  the  effect  of  action  of  the  muscles  of  the  back  and  gluteal  region.     No  history 
of  epilepsy. 

2.  Family  History. —  Sister  (born,  Nov.  6,  1894)  is  an  inmate  of  the  Massachusetts  School  at 
the  present  time,  having  been  admitted  at  the  same  time,  at  the  age  of  7.  There  are  two  other  children, 
not  microcephalic.  The  father  and  mother  were  born  in  Italy,  and  were  about  33  and  23  years  of  age 
respectively  at  time  of  birth  of  patient.  There  are  two  other  children,  one  of  which  was  older  than  the 
patient's  sister. 

Parents  are  said  to  have  been  normal  at  time  of  the  birth ;  birth  was  normal ;  and,  although  it  was 
stated  that  the  labor  in  the  case  of  patient's  microcephalic  elder  sister  was  a  tedious  labor  with  slow  dila- 
tation, the  delivery  was  not  instrumental  in  the  case  of  either  of  the  two  microcephalic  children. 

3.  Personal  and  Developmental  History. —  Patient  seemed  to  the  parents  never  to  have 
developed  mentally.     He  is  described  as  having  been  fed  but  once  a  day,  on  bananas  only. 

4.  History  of  School  Progress. —  Nil. 

5.  School  Examinations. —  Nil. 

6  and  7.  Practical  Knowledge  and  Economic  Efficiency. —  Nil  except  for  statements  made 
under  Physical  Examination  (see  above). 

8.  Social  History  and  Reactions. —  Limited  to  interest  in  food  on  the  instinctive  level;  would 
continue  eating  indefinitely  if  food  was  supplied.     Patient  wanted  to  be  let  alone. 

9.  Moral  Reactions. —  Occasional  crying  spells,  possibly  related  to  appetite. 

10.  Psychological  Tests. —  Quantitative  tests  not  made.  The  microcephalic  elder  sister, 
obviously  a  little  superior  to  her  brother,  measures  1.3  years  of  mental  age  by  Binet  scale.  It  is  clear 
that  the  present  case  would  have  measured  one  year  or  less. 

Waverley  School  History. —  Patient's  condition  was  unchanged  throughout  his  stay.  Patient 
was  admitted  April  12,  1902,  when  five  years  old,  and  died  May  21,  1902. 

b)    Autopsy. 

Notes  not  available;  findings  are  limited  to  Gross  anatomical  examination:  Microcephaly,  dorso- 
spinal  caries,  with  antero-lateral  curvature;  thighs  sharply  flexed  on  abdomen,  legs  flexed  on  thighs, 
arms  slightly  flexed  and  contractured  at  elbows. 

c)  Special  Anatomical  Description  of  Brain. 

The  measurements  of  the  microcephalic  brain,  after  preservation  in  formaldehyde  for  11  years, 
were  as  follows:  — 

Length  of  left  hemicerebrum  LLH,  9  cm. 

right  LRH,  8.25  cm. 

Greatest  width  W  8.75  cm. 
Greatest  height  Heit  5  cm. 

W  V  100 
Cerebral  index    T       ,,     =  97.22  cm. 
Length 

Greatest  width  left  hemicerebrum  WLH,  4  cm. 

right  WRH,  4.75  cm. 

Arc  frontal  pole  to  Rolando  left      LArc  FRo  3.08  cm. 

right    RArc  FRo  3.07  cm. 
Arc  left  Rolando  to  occipital  pole  LArc  RoOc,  5.2  cm. 
right  RArc  RoOc,  4.7  cm. 


WAVERLEY   RESEARCHES.    II.  65 

The  brain  gives  the  impression  of  being  very  simple  and  slightly  developed.  There  seems  to  be  a 
moderate  degree  of  generalized  thickening  of  the  pia  mater  over  the  entire  brain.  The  vessels  are 
prominent  but  fail  to  show  gross  changes.  It  is  noteworthy  that  the  left  hemisphere  is  longer  than  the 
right.  The  olfactory  sulcus  of  the  left  orbital  surface  is  short  and  possesses  distal  extremity  deflected 
to  the  left.  The  olfactory  sulcus  of  the  right  orbital  surface  is  straight  and  extends  almost  to  the  ante- 
rior pole.  The  sulci  on  each  orbital  surface  external  to  the  olfactory  sulci  are  small  triradiate  sulci 
whose  extremities  extend  forward  and  sidewise  well  toward  the  margins  of  the  orbital  surfaces.  Poste- 
riorly these  sulci  approach  the  olfactory  trigone. 

The  markings  of  the  convexity  are  atypical  and  more  markedly  atypical  on  the  right  side.  The 
frontal  lobes  consist  of  but  two  convolutions,  the  superior  of  which  are  broader  than  the  inferior  and 
marked  by  a  number  of  short  fissures.  The  inferior  frontal  convolutions  are  but  slightly  indented  and 
fail  to  cover  in  the  island  of  Reil.  This  deficiency  of  the  frontal  operculum  is  more  marked  on  the  left 
side  than  on  the  right. 

The  central  area  of  the  left  convexity  approaches  normal  in  structure,  although  the  frontal  sulci 
run  back  to  cover  the  precentral  convolution.  Upon  the  right  side,  the  post-central  gyrus  is  folded 
over  the  precentral  gyrus,  forming  an  atypical  operculum  therefor.  The  right  postcentral  gyrus  is  situ- 
ated nearly  a  centimeter  anterior  to  the  left.  Like  the  left  central  area,  the  left  parietal  lobe  has  an 
abnormal  construction;  this  is  divided  atypically  by  the  interparietal  fissure;  the  postcentral  and  hori- 
zontal portions  of  the  left  interparietal  fissure  are  connected  with  each  other.  The  anterior  third  of  the 
left  interparietal  fissure  gives  off  a  short  descending  branch,  which  branch  separates  the  submarginal 
from  the  angular  gyrus. 

The  occipital  lobes  upon  both  sides  are  exceedingly  small  and  scarcely  marked  by  fissures  or  depres- 
sions. On  the  left  side,  the  demarcation  of  the  occipital  from  the  parietal  lobe  is  effected  by  means  of 
the  transverse  operculum.  The  general  appearance  of  this  area  suggests  the  "  Affenspalte " ;  on  both 
sides  the  posterior  extremity  of  the  calcarine  fissure  is  found  to  extend  to  the  external  surface  of  the 
hemisphere.  Upon  the  left  side  this  extremity  terminates  in  a  single  cleft,  pointing  laterally.  On  the 
right  side,  the  extremity  of  the  calcarine  fissure  is  a  cleft  running  more  frontalwards  and  finally  termi- 
nating in  a  T-shape. 

The  comparatively  large  temporal  lobes  are  almost  entirely  without  sulcal  markings,  if  we  except 
the  left  second  temporal  gyrus,  which  is  crossed  by  two  transverse  fissures  in  its  middle  and  posterior 
portions.  The  pyriform  lobule  is  well  developed  on  both  sides,  especially  on  the  right.  Each  pyriform 
lobule  is  marked  off  by  a  distinct  fissura  rhinica  (Turner). 

The  lateral  situation  of  the  hippoeampal  lobes  yields  a  notable  degree  of  exposure  of  the  crura  cerebri 
and  this  appearance  of  an  exposure  of  the  crura  is  increased  by  the  comparatively  small  number  of  trans- 
verse pontine  fibers.  Upon  removal  of  the  pia  mater,  the  transverse  pontine  fibers  are  found  arranged 
in  bundles  which  are  almost  distinct  from  one  another.  The  optic  tracts  seem  comparatively  very  large 
and  the  olivary  and  pyramidal  eminences  upon  the  ventral  surface  of  the  medulla  also  stand  out  promi- 
nently.    The  cerebellum  appears  to  be  not  remarkable  on  gross  inspection. 


d)  and  e)     Microscopic  Examination  and  Anatomical  and  Histological  Summary. 

Upon  section  the  lateral  ventricles  show  a  moderate  degree  of  dilatation.  There  is  a  slight  subpial 
gliosis,  involving  both  an  increase  of  cells  and  an  increase  of  neuroglia  fibrils.  Further  points  so  far  as 
important  are  placed  in  the  general  summary  below. 

Summary  of  Anatomical  Examination. —  The  brain  as  a  whole  is  very  small.  The  cortex  averages 
roughly  3  mm.  in  thickness.  There  are  only  two  convolutional  divisions  in  the  frontal  lobes.  The 
right  post-central  gyrus  forms  an  operculum  which  overlies  the  precentral  nearly  throughout  its  entire 


66  SOUTHARD   AND  TAFT. 

length.  The  sulci  of  the  precentral  area  are  shallow;  the  individual  gyri  (especially  on  the  left)  are  very 
narrow  —  some  are  not  separated  by  sulci  —  and  form  thin  fingers  of  white  surrounded  by  grey  cortex. 
The  lateral  ventricles  are  moderately  large.  In  the  postcentral  (parietal)  area,  the  sulci  are  deeper  than 
precentral  (frontal)  but  the  medullary  portion  of  the  gyri  is  narrow.  The  descending  ventricular  horns 
are  widened  laterally.  The  structures  at  the  base  of  the  brain,  though  small,  are  not  otherwise  abnormal. 
The  tapetum,  optic  radiations,  and  anteroposterior  bundles  are  present.  The  striae  of  Lancisi  (Indusium) 
are  very  noticeable  in  the  anterior  plane.  The  left  is  much  larger  than  the  right  but  decreases  in  size 
posteriorly  until  in  the  region  of  the  Splenium,  they  are  scarcely  distinguishable. 

The  inferior  olives  stand  out  prominently  from  the  periphery  of  the  medulla;  a  distinct  cleft  exists 
on  their  antero-lateral  surface,  separating  them  from  the  surrounding  portions,  and  the  anterior  arcuate 
fibers  curve  in  deeply  around  the  depth  of  this  cleft. 

The  cortex  is  of  average  thickness  (3  mm.).  The  cell  supply  is  scant  in  all  layers,  but  notably  so  in 
the  medium  sized  and  large  pyramid  layers,  especially  in  the  frontal  and  parietal  areas.  Many  of  the 
Betz  cells  are  thin  and  fusiform.     This  seems  particularly  true  of  the  left  side. 

The  leaflets  of  the  cerebellum  are  small,  but  do  not  lack  in  normal  elements,  nor  present  any  anomaly. 

The  blood  vessels  are  not  remarkable. 


Synopsis  of  Findings  of  Case  II. 
a)  Clinical. 

1.  Physical  Examination. —  Born  September  3,  1876;  admitted  to  the  school,  April  1,  1893; 
died  March  11,  1897.  Characteristic  microcephalic  with  receding  forehead;  knees  stiff  and  flexed;  feet 
extended;  ankles  rigid;  thighs  crossed ;  right  knee  crossed  left;  legs  in  contracture;  hips  can  be  slightly 
flexed;  spastic  paralysis  of  right  arm;  locomotion  by  rolling;  patient  could  feed  himself  by  use  of  left 
arm  and  hand;  patient  unable  to  walk  or  sit;  head  is  described  as  asymmetrical.  The  right  hemisphere 
of  the  brain  is  described  at  autopsy  as  having  been  one  third  larger  than  the  left,  and  the  skull  flattening 
is  described  as  having  been  especially  marked  in  the  left  frontal  region.     No  evidence  of  epilepsy. 

2.  Family  History. —  Born  in  Provincetown,  of  American  parents;  father  25  years  of  age,  mother 
22  years  of  age  at  birth  of  child.  The  microcephalic  child  was  the  first,  seven  other  children  following, 
none  of  whom  is  described  as  showing  any  deformity.  The  mother's  health  during  pregnancy  is  de- 
scribed as  having  been  good,  and  no  extraordinary  circumstances  attended  the  delivery. 

3.  Personal  Developmental  History. —  Physician  (Dr.  Newton)  described  the  patient  as  having 
had  a  paralytic  shock,  at  what  time  before  the  age  at  which  first  peculiarity  was  noticed  (3  months) 
cannot  now  be  stated.  Another  version  of  the  cause  is  "infantile  paralysis,"  but  whether  this  diagnosis, 
made  in  1876,  has  reference  to  epidemic  poliomyelitis  cannot  now  be  stated.  The  patient  is  described 
as  having  passed  through  measles,  whooping  cough,  and  chicken  pox. 

4  and  6.     School  Progress  and  Examinations. —  Nil. 

6.  Practical  Knowledge. —  Able  to  feed  himself  with  left  arm  and  hand. 

7.  Economic  Efficiency. —  Nil. 

8.  Social  History  and  Reactions. —  Patient  appears  to  understand  certain  things  said  to  him. 
Unable  to  talk.  (Is  described  by  family  as  able  to  say  "Mamma.")  Patient  could  make  cackling 
sounds  of  a  loud  and  shrill  nature.  By  means  of  these  sounds  and  by  gesticulating  with  the  left  hand, 
patient  was  able  to  express  clearly:  pain,  pleasure,  displeasure,  hunger,  and  thirst;  and  was  apparently 
able  to  make  the  other  boys  in  the  ward  able  to  understand  these  expressions.  Patient  took  interest  in 
events  about  him,  watching  the  boys  at  play,  liking  to  look  at  pictures  and  bright  colors.  Patient's 
hearing  was  good.     He  enjoyed  music  and  was  able  to  hum  several  tunes  correctly. 


WAVERLEY  RESEARCHES.    II. 


67 


9.  Moral  Reactions. —  Patient  is  described  as  gluttonous,  swallowing  food  without  chewing. 
He  is  described  by  the  family  as  passionate. 

10.  Psychological  Tests. —  No  quantitative  tests  made.  Patient  would  probably  measure  less 
than  a  year. 

Waverley  School  History. —  Is  sufficiently  described  above.  Death  was  due  to  septicaemia 
following  gangrene  of  extremities. 

b)    Autopsy. 

The  description  of  the  autopsy  is  taken  from  the  report  of  Dr.  Taylor: 

The  autopsy  was  made  about  twenty-four  hours  after  death,  the  head  only  being  examined.  The 
body  was  undersized  and  markedly  deformed.  The  head  was  markedly  microcephalic  in  type,  the 
circumference  17J  inches;  from  root  of  the  nose  to  the  occipital  protuberance  measured  11  inches.  The 
skull  was  thick,  particularly  over  the  parietal  regions.  Corresponding  to  two  marked  depressions  in 
the  frontal  portion  of  the  brain  and  easily  seen  before  the  removal  of  the  dura  were  two  bony  promi- 
nences on  the  inner  table  of  the  skull.  Dura  and  pia  normal.  The  brain  completely  filled  the  cranial 
cavity,  which  was  asymmetrical.  The  left  hemisphere  was  markedly  smaller  than  the  right,  with  ab- 
normal convolutions  in  both.  Very  striking  at  the  autopsy  was  the  posterior  portion  of  the  brain, 
including  the  upper  parietal  and  occipital  lobes.  The  cortex  here  was  so  greatly  reduced  in  thickness 
that  fluctuation  from  the  distended  ventricle  was  easily  obtained  on  the  left  side.  The  right  hemisphere 
appeared  approximately  thirty-three  and  one  third  percent,  larger  than  the  left. 

The  brain  was  hardened  in  formalin,  and  after  hardening  weighed  620  grams. 

Further  examination  of  the  brain  16  years  after  removal  yielded  the  following  measurements:  — 

Length  of  left  hemicerebrum,  LLH,  14.5  cm. 

right  LRH,  14.5  cm. 

Greatest  width  W  11  cm. 

_     .     .  .    .       W  X 100      na 

Cerebral  mdex,  -= -r-  =  76  cm. 

Length 

Greatest  height  Heit  5.75  cm. 

Greatest  width  left  hemicerebrum  WLH,  5.  cm. 

right  WRH,  6.  cm. 

Arc  frontal  pole  to  Rolando  LArc  FRo  8.    Left. 

right  RArc  FRo  9.5  cm. 

Arc  left  Rolando  to  occipital  pole,  LArc  RoOc,  6.5  cm. 

right  RArc  RoOc,  5.  cm. 

Frontal  pole  to  corpus  callosum,  FCorp  Cal.  3.2  cm. 

Right  optic  commissure  6  cm. 

There  is  considerable  asymmetry  in  this  brain.  The  hemispheres  do  not  differ  materially  in  length, 
but  the  right  is  considerably  broader  than  the  left.  This  is  particularly  noticeable  at  the  frontal  pole. 
On  the  orbital  surface  the  left  gyrus  rectus  is  narrower  than  its  opposite,  and  the  convolution  which 
forms  the  margin  is  shrunken  and  shortened.  This  shortens  the  distance  from  the  frontal  tip  to  the 
fronto-temporal  angle,  and  deflects  the  longitudinal  fissure  toward  the  left. 

There  is  a  circumscribed  area  of  microgyria  about  midway  the  second  frontal  gyrus  on  either  side, 
that  on  the  left  is  more  extensive.     The  third  left  frontal  is  complex  and  the  convolutions  are  well  rounded. 

The  central  region  marks  the  beginning  of  an  extremely  atypical  cortex.  The  precentral  gyrus  on 
both  sides  is  of  fair  width,  and  well  rounded.  The  postcentral  on  both  sides  is  much  shrunken  and 
narrowed  in  its  upper  half.  The  fissure  of  Rolando  very  nearly  cuts  the  margin  of  the  superior  longi- 
tudinal fissure  on  the  left,  while  on  the  right,  its  upper  extremity  is  one  centimeter  from  the  margin. 


68 


SOUTHARD  AND  TAFT. 


The  entire  parietal  cortex  over  the  vertex  is  much  shrunken,  the  convolutions  are  very  narrow  and 
flat,  and  on  the  left  a  small  focus  has  sunken  below  the  surrounding  surface.  The  normal  markings  are 
not  made  out,  on  account  of  the  alterations  in  the  cortex.  At  the  parieto-temporal  juncture,  the  con- 
volutions assume  a  more  nearly  normal  outline.  This  does  not  include  the  upper  part  of  both  the  supra- 
marginal  and  angular  gyri  on  both  sides,  both  of  which  are  severely  affected;  more  particularly  the 
former  and  the  cortical  change  is  more  extensive  and  extreme  on  the  left  than  the  right. 

The  temporal  lobes  are  asymmetrical  temporo-frontal  distance  L.  4.  cm.     Rt.  4.5  cm. 

Both  first  temporals  are  very  narrow;  the  right  particularly  so.  The  second  temporals  are  broad 
with  transverse  markings.  The  left  hippocampal  gyrus  is  completely  hidden  by  the  folding  over  of  the 
third  temporal,  and  only  the  extreme  anterior  portion  of  the  pyriform  lobule  is  seen.  On  the  right,  the 
hippocampus  and  pyriform  lobule  are  not  remarkable. 

The  occipital  lobes  are  very  small  and  show  the  same  changes  on  the  superior  surface  as  the  parietal 
upper  regions;  the  lateral  surfaces  are  more  nearly  normal.  The  posterior  extremity  of  the  calcarine 
fissure  extends  well  on  to  the  outer  surface  of  the  occipital  tip.  On  the  left,  the  distortion  of  the  parietal 
cortex  has  brought  the  calcarine  fissure  for  a  considerable  distance  nearly  to  the  upper  margin  of  the 
hemisphere. 

The  pons,  medulla,  and  cerebellum  are  not  notable  on  gross  examination. 

d)    Microscopic  Examination. 

Nerve  fibers  have  been  replaced  in  many  instances  by  patches  of  rather  dense  neuroglia  tissue.  In 
the  prefrontal  sections  this  condition  is  marked,  especially  on  the  right  side;  farther  back  the  areas  of 
gliosis  show  cavitation  with  numerous  glia  cells  in  rather  thin  encapsulating  walls,  and  a  number  of  large 
pigment-bearing  phagocytes.  The  major  amount  of  cell  loss  is  in  this  portion  of  the  frontal  region  con- 
fined to  the  mesial  surface.  Farther  back  the  frontal  cortex  shows  thinning  of  all  its  layers,  except  the 
external  layer  of  small  pyramids.  More  posteriorly  the  total  brain  sections  demonstrate  a  special  loss 
in  size  of  the  two  second  frontal  convolutions;  but  this  loss  is  more  marked  on  the  left  than  upon  the 
right  side.  The  mesial  gyri  in  this  region  are  also  characterized  by  extreme  fiber  loss,  and  the  cells  which 
persist  are  arranged  patchily.  The  sections  here  indicate  that  there  are  more  nerve  cells  than  the  num- 
ber of  persistent  nerve  fibers  would  lead  one  to  expect.  More  posterior  sections  exhibit  the  same  higher 
degree  of  degeneration  upon  the  left  side  and  this  degeneration  is  shared  by  both  the  second  and  the  first 
frontal  gyri.  Sections  through  the  plane  of  the  anterior  extremity  of  the  lateral  ventricles  show  a  marked 
dilatation  upon  the  left  side,  with  a  complete  degeneration  of  the  fibers  surrounding  the  ventricle  supe- 
riorly, externally  and  upon  the  external  half  of  the  inferior  border,  whereas  the  fibers  on  the  mesial  border 
and  upon  the  internal  half  of  the  inferior  border  of  the  ventricle  are  preserved.  The  fiber  communica- 
tions of  the  first  and  second  frontal  gyri  that  underlie  portions  of  the  brain  are  represented  by  only  a 
narrow  band  of  fibers. 

When  the  sections  begin  to  cut  the  corpus  callosum,  it  is  found  that  this  body  is  made  up  of  a  very 
thin  bundle  with  a  small  number  of  stained  fibers.  The  white  bundle  and  the  third  left  frontal  gyrus 
are  thinned  out  and  in  this  region  there  are  many  large  pigmented  phagocytes.  The  first  and  second 
frontal  gyri  in  this  plane  are  almost  completely  degenerated  as  is  also  the  tissue  of  the  superior  mesial 
surface.  The  knee  of  the  corpus  callosum  is  also  very  thin.  The  lower  portions  of  the  hemisphere 
appear  more  nearly  normal  than  the  upper  portions,  although  the  gyri  in  the  lower  portions  of  the  hemi- 
spheres are  too  narrow  and  long  as  compared  with  normal.  Some  sections  exhibit  a  multiple  cavitation 
in  the  degenerated  areas  with  the  cavities  surrounded  by  a  dense  gliosis.  In  a  plane  still  farther  back 
behind  the  temporal  lobes,  a  considerable  degree  of  satellitosis  is  found  in  both  superior  frontal  gyri. 
The  lateral  ventricles  are  markedly  dilated,  although  the  left  more  so  than  the  right.     Small  areas  of 


WAVERLEY  RESEARCHES.    II.  69 

Betz  cells  are  found  in  the  precentral  gyri  on  each  side,  although  the  tissue  for  the  most  part  above  the 
temporal  lobes  is  markedly  degenerated.  In  view  of  this  marked  degeneration,  the  internal  capsule 
does  not  appear  to  be  so  shrunken  a  structure  as  one  might  expect.  The  superior  temporal  gyrus  is 
itself  moderately  involved  in  the  degeneration,  more  particularly  on  the  left  side.  The  transverse 
temporal  gyri  are  markedly  shrunken.  Planes  posterior  to  the  above  continue  to  show  extreme  degenera- 
tion of  tissues  superior  to  the  Sylvian  fissure  and  even  including  the  mesial  surface  on  the  left  side.  Of 
these  gyri  the  callosal  gyri  are  the  least  affected.  The  superior  temporal  gyri  and  insulae  of  both  sides 
show  equal  degrees  of  degeneration.  On  the  right  side,  the  inferior  parietal  lobule  shows  a  certain  degree 
of  change,  but  the  alteration  of  the  superior  parietal  lobule  is  extreme,  if  we  except  the  tissue  along  the 
longitudinal  fissure  and  upon  the  mesial  surface.  Large  amyloid  granulations  are  found  at  the  base  of 
the  pineal  body. 

The  thinning  of  the  cortex  in  sections  posterior  to  the  above  is  extreme  except  in  the  temporal  lobes. 
Appearances  suggest  that  the  right  superior  colliculus  is  smaller  than  the  left.  The  pyramidal  bundles 
are  smaller  on  the  left  side  than  on  the  right,  their  magnitude  being  reduced  possibly  one  third.  The 
tapetum  and  optic  radiations  are  markedly  thinned  out  on  both  sides,  although  more  extremely  on  the 
left.  A  section  from  the  extreme  tips  of  the  right  lobe  exhibits  a  curious  appearance  of  cells  in  islands 
separated  by  fibers. 

e)     Anatomical  and  Histological  Summary. 

The  interest  of  this  case  naturally  lodges  in  the  combination  of  microcephaly,  hydrocephalus  and 
posterior-lying  focal  lesion  of  the  cerebral  cortex.  It  is  supposed  that  this  latter  lesion  may  have  been 
due  to  an  old  cortical  lesion,  possibly  of  the  nature  of  cerebral  lesions  sometimes  occurring  in  infantile 
paralysis.  The  brain  is  somewhat  asymmetrical;  in  particular  the  right  hemisphere  is  considerably 
broader  than  the  left.  It  is  an  interesting  inquiry  what  relation  may  be  held  between  the  focal  parietal, 
occipital  lesion  and  the  shrunken  left  frontal  region  with  its  circumscribed  area  of  microgyria  in  the  second 
frontal    gyrus. 

When  we  find  that  the  nerve  fiber  loss  has  been  replaced  by  patches  of  rather  dense  neuroglia  tissue, 
we  are  bound  to  inquire  whether  this  latter  condition  of  gliosis  is  to  be  regarded  as  an  acquired  reaction 
following  the  destruction  of  tissue  which  had  been  properly  laid  down,  or  whether  this  gliosis  is  to  be 
regarded  as  gliosis  relative  to  fundamental  absence  of  nerve  fibers.  The  patchy  nature  of  the  gliosis 
rather  inclines  the  examiner  to  the  belief  that  we  are  dealing  with  a  lesion  in  some  sense  acquired.  The 
fact  that  large  pigment-bearing  phagocytes  are  found  in  the  gliotic  walls  of  the  cavities  found  in  some 
areas  of  gliosis  is  perhaps  not  decisive;  but  phagocytosis  is  consistent  with  the  hypothesis  of  acquired 
lesion. 

Again  the  irregular  preservation  of  nerve  fibers  about  the  ventricle  (mesial  and  internal  fibers  of  the 
inferior  border  preserved)  rather  suggests  acquired  lesion. 

What  the  significance  of  the  multiple  cavitation  in  degenerated  areas  surrounded  by  dense  gliosis 
may  be  is  doubtful.  We  may  think  of  the  resemblance  of  these  areas  to  cavitation  in  the  spinal  cord  in 
syringomyelia.  Patchy  nerve  cell  and  fiber  loss,  cavitation  in  areas  of  gliosis,  the  occurrence  of  pigment- 
bearing  phagocytes,  to  say  nothing  of  the  somewhat  suggestive  history  of  early  brain  lesion,  may  well 
lead  us  to  regard  this  case  as  one  of  secondary  amentia  in  the  sense  of  Tredgold.  Whether  we  may 
add  to  this  list  of  factors  the  presence  of  satellitosis  in  certain  areas  is  questionable.  On  the  whole, 
however,  in  the  present  stage  of  our  knowledge  concerning  satellitosis,  it  would  appear  that  the  finding 
is  rather  indicative  of  an  active  or  acquired  lesion.  (One  here  bears  in  mind  the  satellitosis  about  nerve 
cells  in  poliomyelitis  and  other  conditions,  which  may  be  repeated  experimentally;  but  one  also  has  to 
bear  in  mind  the  satellitosis  in  certain  cases  of  atrophy  of  the  brain  in  the  senile  period  where  the  satellite 
cells  may  be  regarded  possibly  as  reactive  to  the  condition  of  atrophy.)     It  might  be  that  hypoplastic 


70  SOUTHARD  AND  TAFT. 

nerve  cells  could  be  affected  by  satellitosis  in  ways  identical  with  those  of  the  condition  just  mentioned. 
The  presence  of  large  amyloid  granulations  at  the  base  of  the  pineal  body  may  have  significance  in  these 
directions  but  we  must  at  present  omit  consideration  thereof. 

The  greater  degree  of  disease  on  the  left  side  of  the  brain  is  supported  by  the  smaller  size  of  the  pyra- 
midal bundles  on  the  left  side  above  the  decussation. 

In  our  judgment  the  case  then  is  pretty  clearly  one  of  secondary  amentia. 


Synopsis  of  Findings  in  Case  III. 
a)  Clinical. 

Little  is  known  as  to  Case  III  although  the  patient,  D.  C,  born  in  1863,  was  a  somewhat  well-known 
figure  in  Boston  and  vicinity  all  his  life,  which  was  passed  for  the  most  part  outside  of  institutions.  When 
outside  of  institutions,  patient  was  regarded  as  a  harmless  microcephalic,  alternately  the  pet  and  the 
butt  of  the  community.  He  was  of  a  vagrant  tendency,  unable  to  support  himself  but  able  to  curry 
favor  with  various  kindhearted  persons,  who  would  keep  him  in  their  houses  for  a  few  days  or  weeks 
until  the  vagrant  spirit  set  in  once  more.  He  was  known  as  "Peanut  head"  by  the  children,  and  became 
later  known  as  "Zip,"  being  a  namesake  of  a  subject  exhibited  at  circuses  and  variety  shows.  In  fact, 
the  patient  is  said  to  have  been  exhibited  for  a  time  in  a  nickel  theatre  in  Boston  under  the  name  of 
"Zip,  the  wild  man  of  the  Philippines."  The  patient  entered  the  hoax  with  intelligence,  wore  a  buffalo 
robe,  had  his  hair  cut  in  a  peak  behind,  and  rattled  a  tin  cup,  saying  "Education!     Education!" 

The  patient,  born  of  Irish-American  parents  (father  alcoholic),  is  said  to  have  been  a  seven-months 
child,  born  in  a  fracas  between  his  father  and  a  policeman.  The  patient's  father  is  said  to  have  been 
occupied  with  beating  the  mother  when  the  policeman  interposed.  The  policeman's  club  is  said  to  have 
glanced  off  onto  the  head  of  the  mother,  who  died  within  twelve  hours  of  giving  birth  to  the  patient. 

The  patient  is  said  to  have  learned  to  walk  and  talk  at  the  usual  time,  was  unable  to  get  through 
the  primary  school,  but  is  said  to  have  picked  up  reading  and  writing.  He  was  at  first  in  a  Catholic 
home;  later  in  a  home  for  destitute  children;  still  later  in  the  State  Infirmary  in  Tewksbury,  where  he 
was  operated  upon  for  rupture;  and  he  was  at  the  Bridgewater  State  Farm  in  1903.  The  patient  had 
no  abnormal  sexual  tendencies.  He  was  easily  susceptible  to  alcohol.  It  is  said  that  at  the  age  of  30 
he  had  a  fit,  probably  epileptic  in  nature. 

The  history  of  the  patient  just  before  his  death  makes  a  somewhat  moving  story.  Upon  good 
authority,  it  is  related  that  he  was  in  perfect  health  until  September  15,  1908,  being  six  days  before  he 
died.  Upon  September  15,  the  patient  endeavored  to  steal  a  quarter  from  a  kind  hostess  who  had  kept 
him  in  her  house  for  a  number  of  days,  as  she  had  done  at  previous  times.  He  was  found  out  in  his 
design  and  was  upbraided  roundly  by  his  hostess  for  being  a  liar.  The  patient  became  furious,  went  to 
his  room  in  his  hostess'  house,  began  to  mutter  to  himself  and  to  tear  his  hair,  and  then  refused  to  eat  or 
drink.  He  is  said  not  to  have  eaten  anything  until  his  death.  He  was  admitted  to  the  Danvers  State 
Hospital  in  extremis,  September  20,  1908,  and  died  a  few  hours  later. 


WAVEKLEY   RESEARCHES.    II.  71 


b)  Autopsy. 

Head  and  trunk  were  examined  by  E.  E.  Southard  and  the  cord  by  M.  M.  Canavan. 

White  male,  age  45,  126  cm.  long;  weight,  88  lbs.  Trunk  symmetrical;  thorax  narrow;  costal 
angle  acute.  Shoulders  and  hips  of  equal  width.  Spinal  column  straight.  Extremities  symmetrical 
and  of  appropriate  length  with  respect  to  trunk.     Head  microcephalic.     Skull  symmetrical. 

Measurements:    Glabello-occipital  length,  14.5 

Basi-bregmatic  height,  12. 

Vertical  index,  81 . 

Minimum  frontal  diameter,  9.5 

Greatest  parietosquamous  breadth,  11.5 

Cephalic  index,  79. 

Horizontal  circumference,  43. 

The  glabella  is  prominent.     The  general  outlines  are  shown  in  the  accompanying  sketch.     Extremities 
rigid.     Slight  greenish  discoloration  of  abdomen.     Pupils:  left  5  mm.,  right  4  mm. 

Peritoneal  cavity. —  Serosa  and  contents  normal.  Appendix  infracecal,  free,  7  cm.  long.  Mesen- 
teric lymph  nodes  not  enlarged.     Omentum  thinly  clad  with  fat. 

Pleural  cavities. —  Slightly  moister  than  normal.  Adhesions  absent.  Roughening  of  pleura  at 
both  apices,  in  areas  less  than  3  cm.  broad. 

Pericardial  Cavity. —  Not  remarkable. 

Mediastinum. —  No  sign  of  thymus. 

Heart. —  Weight,  210  grams. 

Measurements:    T.  V.     11.  cm.       P.  V.     5  cm.     L.  V.     1.5  cm. 
M.V.      9.  cm.      A.  V.     6  cm.     R.  V.    0.4  cm. 

Muscle  normal.  Endocardium  shows  a  slight  thickening  adjacent  to  aortic  valve.  Valves  normal. 
Cavities  contain  cruor  clot.     Coronary  arteries  normal. 

Lungs. —  Left  355  gr. ;  right  535  gr.  Both  edematous  and  congested  behind  and  below.  The 
dependent  portions  of  both  lungs,  especially  right,  are  coarsely  mottled  and  non-retractile,  and  contain 
bronchial  plugs  of  semifluid  pus.  There  is  no  palpable  deposit  of  fibrin  on  the  pleurae.  The  larger 
bronchi  are  free  from  pus.     The  vessels  are  normal.     Bronchial  lymph  nodes  not  remarkable. 

Spleen. —  Wt.  105  gr.  Fir;  dark  red,  without  thickening  of  trabeculae  or  enlargement  of  malpighian 
bodies.     Splenculus  near  hilus  below. 

Gastro  intestinal  tract. —  Stomach:  Contains  little  or  no  fluid.  Walls  covered  with  brownish  mucus 
which  is  tenacious.  Duodenum  negative,  also  jejunum.  In  various  parts  of  the  ileum  greenish  black 
semi-solid  pasty  material  seen.  Walls  covered  with  mucoid  exudate.  No  ulceration  or  hemorrhage 
seen.  The  colon  also  for  some  distance  after  passing  ileocecal  valve  shows  black  content,  but  at  the  sig- 
moid the  content  is  only  cheesy  mucoid  material.     Rectum  negative. 

Liver:  Wt.  990  gr.  Border  sharp.  Substance  of  normal  consistence  and  nut-brown  in  color.  Gall 
bladder  not  remarkable. 

Pancreas. —  Small. 

Adrenals. —  Show  no  lesion. 

Kidneys. —  Left  weighs  170  gr.  Measures  13  X  5  cm.,  is  very  red  and  drips  blood  on  section.  The 
capsule  strips  with  fair  ease  leaving  a  smooth  surface.  The  cortex  is  1  cm.  thick,  the  pyramids  are  a 
large  distance  from  pelvis  to  capsular  surface,  being  2.5  cm.  The  pyramids  are  uniformly  diffusely  red, 
while  the  cortex,  mahogany  in  color,  is  markedly  injected.  Kidney  substance  bulges  on  section.  Two 
ureters  of  usual  size  connect  the  kidney  with  the  bladder.     The  right  kidney  measures  9  X  2.5  cm. 


72  SOUTHARD  AND  TAFT. 

Two  yellow-white  pouches  2.5  X  3  cm.  in  diameter,  spring  from  either  pole  of  the  kidney  and  descend 
to  bladder  as  independent  tubes  1.4  cm.-l  cm.  in  diameter.  They  are  14-18  cm.  in  length  and  above 
the  fundus  of  the  bladder  appear  to  unite  and  descend  on  right  side  of  bladder.  The  bladder  is  deeply 
congested  and  in  the  upper  and  right  side  numerous  cysts,  closely  set,  appear  in  wall.  Dissection  of  the 
ureters  shows  fine  openings  into  the  bladder,  two  on  the  left  side  corresponding  with  the  two  ureters  and 
situated  appropriately  with  relation  to  the  trigonum,  two  on  the  right  side  symmetrically  placed  with 
respect  to  those  of  the  left  side  but  draining  only  the  external  of  the  two  right  ureters.  The  internal  of 
the  right  ureters  opens  into  the  bladder  by  a  relatively  large  orifice  situated  on  the  lateral  surface  near 
the  summit. 

Organs  of  neck. —  Thyroid  weighs  15  gr.  Normal  on  section.  Under  and  along  upper  border  of 
common  carotids  a  glandular  bit  of  tissue  held  together  by  adipose  and  areolar  tissue  seen.  It  is  yellow 
in  color  and  contains  numerous  glistening  red  bodies. 

Aorta. —  Smooth  and  elastic  throughout. 

Genito  urinary. —  Testes  yellow-white,  small,  edematous,  do  not  thread  well. 

Head. —  Hair  stiff,  black,  closely  cropped.  Scalp  thick  and  may  be  readily  gathered  into  loose 
folds.  Calvarium  moderately  dense.  Dura  mater  not  adherent  to  calvarium.  Sinuses  not  remarkable. 
Middle  ears  normal.  Pituitary  body  normal.  Brain  wt.  610  gr.  Placed  in  formalin  for  later  description. 
Brain  reweighed  after  formalin  containing  8%  NaCl,  615  grams. 

Measurements:     Cerebrum,  antero-posterior, 
"  dorso-ventrally, 

"  laterally, 

Cerebellum,  antero-posterior  left, 
"  "  "  right, 

"  greatest  dorso-ventrally, 

"  laterally, 

Width  of  pons  between  origins  of  5th  nerves,  3  cm. 

Antero-posterior  basal  measurement  of  pons,  2.5  cm.. 

Pia  mater,  everywhere  clear.  Vessels  show  moderate  injection;  small  pacchionian  granulations 
alongside  longitudinal  fissure  from  middle  of  superior  frontal  gyri  as  far  back  as  superior  parietal  lobules. 
Sylvian  and  Rolandic  fissures  well  marked,  almost  symmetrical.  Gyri  of  fairly  even  width.  Gyri  and 
sulci  so  disposed  as  to  yield  the  impression  of  a  normal  though  small  brain.  No  sign  of  Affenspalte. 
Upon  superficial  examination,  besides  Rolandic  and  Sylvian  fissures  are  made  out  (before  stripping  pia), 
ascending  ramus  of  Sylvian,  second  and  third  frontal  sulci,  first  frontal  sulcus  (interrupted),  intraparietal 
sulcus  with  branches,  first  and  second  temporal  sulci,  parieto-occipital,  calcarine,  collateral  and  calloso- 
marginal  sulci.  Orbital  surfaces  normal.  Slightly  asymmetrical  markings.  Cerebellae  laminae  not 
remarkable  possibly  in  places  wider  than  usual,  notably  in  Amygdala.  The  inferior  vermis  is  either 
absent  or  obscured  by  close  proximity  of  inner  surfaces  of  the  amygdalae. 

Anatomical  Diagnosis. 
Unequal  pupils. 
Chronic  pleuritis. 
Slight  chronic  endocarditis. 
Pulmonary  congestion. 
Purulent  bronchitis. 
Acute  nephritis. 
Cystitis,  acute. 

Cystic  formation  in  bladder  wall. 
Abnormality  of  ureters. 


12.5 

cm. 

9. 

cm. 

10.75 

cm. 

4.5 

cm. 

4.5 

cm. 

3.5 

cm. 

8.5 

cm. 

WAVERLEY   RESEARCHES.    II.  73 


Scalp  thick. 
Calvarium  dense. 
Microcephalic  brain. 
Brain  weight,  610  grams. 


c)  Special  Description  of  Brain. 


Subsequent  to  examination  on  the  autopsy  table,  the  following  notes  were  made  concerning  the 
brain: 

Length  left  hemicerebrum,  LLH,     16 . 9  cm. 
right  LRH,    16.2  cm. 

Width  W  12,  10.1. 

Cerebral  index  10.1  X  100,  over  16.9  cm. 
Greatest  height  Heit,  7  cm. 

Arc  frontal  pole  to  Rolando,  LArc  FRo,    9 . 3  cm. 
right,  R Arc  FRo,    9.4  cm. 

Arc  left  Rolando  to  occipital  pole,  LArc  RoOc,    8.4  cm. 
right,  RArc  RoOc,    8.2  cm. 

Angle  of  Rolando  with  long,  fissure  Right  =  53° 

■       "        "  "        "         "       Left  =  53° 

Temporal  tip  —  frontal  pole  =  3.1  cm. 

"  "       occipital  pole  =  10.3  cm. 

Cerebellum. —  Bilateral  diam.  =  8.7  cm. 
Ant.  post,  at  brachial  exit  =  5.2  cm. 

Flocculus  fairly  developed.     Lobes  uniform  in  size  and  outline. 

Fifth  nerve  leaves  the  bulb  somewhat  higher  on  the  right  than  on  left.  Cranial  nerves  otherwise 
not  remarkable. 

Basilar  vessels  show  no  alterations  except  slight  diffuse  thickening  of  the  vertebrals,  especially  seen 
on  the  right  about  2  cm.  below  the  basilar. 

Frontal  segment  mesial  from  corpus  callosum  =  2.5  cm. 

Occipital  segment,  splenium  —  occipital  pole     =  5.7  cm. 

Right  Hemisphere. — ■  The  right  Sylvian  fissure  (6.4  cm.)  is  very  simple,  its  borders  closely  approxi- 
mated.    The  insula  is  visible  only  at  the  base  of  the  ascending  ramus;  there  is  no  anterior  branch. 

Central  Rolandic  Fissure. —  The  Fissure  of  Rolando  is  7.6  cm.  in  length,  has  no  branches  and  does 
not  cut  through  the  margin  of  the  hemisphere.  The  genua  are  represented  by  two  flat  curves  in  the 
course  of  the  fissure.     The  superior  genu  is  1.7  cm.  from  upper  extremity;  the  inferior,  5.3  cm. 

Occipito-parietal. —  Rises  where  the  internal  border  of  the  cortex  cerebri  is  in  apposition  with  the 
ant.  corp.  quad.  It  approaches  the  occipital  pole  in  a  comparatively  horizontal  direction.  At  the 
margin  it  bifurcates,  forming  a  broad  Y.  The  occipito-calcarine  stem  is  short,  1.2  cm.  The  calcarine 
fissure  forms  an  acute  angle  with  the  parietooccipital  and  continues  posteriorly  in  an  S  outline  extending 
downward  and  backward,  then  outward  and  upward. 

The  precentral  fissure-complex.  In  the  frontal  cortex,  including  and  lying  in  front  of  the  fissure  of 
Rolando,  there  is  one  principal  fissure,  triradiate  in  form  corresponding  apparently  to  the  precentral 
sulcus,  frontal  from  which  extends  the  inferior  frontal  sulcus.  Above  the  dorsal  extremity  of  the  vertical 
ramus  and  separated  from  it  by  a  narrow,  plump  gyrus,  is  a  short,  deep  fissure  2.3  cm.  in  length  which 
cuts  the  superior  margin  at  right  angles.  (Sulcus  cruciatus?).  This  sulcal  arrangement  divides  the 
frontal  cortex  into  two  gyri,  both  of  which  anastomose  with  the  precentral  and  anteriorly  with  each  other. 
The  superior  frontal  convolution  is  broad  and  long,  and  is  marked  by  four  short  fissurettes  which  generally 


74  SOUTHARD  AND  TAFT. 

follow  an  oblique  line.  The  inferior  frontal  is  short  and  broad,  and  is  marked  by  three  shallow  fissur- 
ettes,  and  a  deep  ascending  Sylvian  fissure.  Very  far  frontal  is  a  T-shaped  sulcus,  whose  stem  runs  from 
a  point  very  near  the  fronto-Sylvian  angle  and  0.6  cm.  from  the  orbito-frontal  margin  to  a  point  0.8  cm. 
from  the  superior  margin  where  it  opens  into  a  longitudinal  sulcus  2.1  cm.  in  length,  slightly  concave 
mesad. 

Temporal  and  Occipital  Fissures. —  The  parietal  lobe  presents  an  anomalous  fissure-complex  —  the 
postcentral  sulcus  (1)  cuts  the  margin  of  the  superior  longitudinal  fissure  and  extends  upon  the  mesial 
surface  for  a  short  distance.  The  horizontal  interparietal  is  represented  by  a  very  short  ramus  (2) 
(1.5  cm.)  which  springs  from  the  postcentral  at  the  junction  of  the  middle  and  lower  thirds,  mesad  to  this 
horizontal  ramus  and  1.4  cm.  from  the  meso-dorsal  margin  is  a  deep,  curved,  horizontal  fissure,  slightly 
curved  with  the  convexity  mesad.  This  fissure  does  not  descend  vertically  into  the  cortex,  but  obliquely 
outward,  thus  forming  a  thin  operculum  which  overlies  the  tips  of  the  horizontal  convolutions  which 
form  the  superior  parietal  lobule.  At  its  occipital  extremity  this  sulcus  opens  into  a  horizontal  one  4.3  cm. 
in  length  which  lies  1.5  on  the  meso-occipital  surface  and  ends  laterad  in  a  forked  extremity.  The  lower 
lip  of  this  fissure  is  opercular  in  character  and  suggests  an  Affenspalte.  The  corresponding  sulcus  on  the 
left  side  is  quite  simple,  not  at  all  resembling  the  one  just  described. 

The  superior  parietal  lobule  is  narrow  and  its  gyri  vary  in  width  from  1.2  cm.  to  0.4  cm.  The  supra- 
marginal  gyrus  is  fairly  broad  —  0.9  cm.  in  width  —  but  the  convolution  is  short.  It  anastomoses 
anteriorly  with  the  postcentral  and  posteriorly  by  means  of  a  bridging  arm,  with  the  angular  gyrus.  The 
latter  is  made  up  of  three  parts  which  extend  horizontally  and  assume  a  fan-shaped  outline.  The  gyri 
are  comparatively  broad  and  almost  free  from  ramifications.  This  gyrus  encroaches  upon  the  occipital 
lobe  which  is  very  small.  The  tips  of  the  occipital  lobes  of  both  sides  point  away  from  the  median  line 
thus  exposing  a  portion  of  the  cortex  which  is  ordinarily  found  on  the  approximated  mesial  surface. 

The  Temporal  Lobe. —  The  temporal  lobe  is  divided  by  two  very  simple  fissures.  The  gyri  are 
relatively  broad,  smooth  and  well-rounded,  with  short  shallow  fissures  at  their  bases.  The  sulci  on  the 
basal  surface  are  very  simple.  A  deep  fissura  rhinica  separates  the  uncus  definitely  from  the  tip  of 
the  temporal  lobe.  The  inferior  temporal  sulcus:  It  is  deep  with  sloping  walls,  and  is  interrupted 
about  midway  by  an  arm  from  the  fusiform  gyrus  which  anastomoses  with  the  third  temporal  convo- 
lution. 

The  Left  hemicerebrum. —  The  configurations  of  the  area  anterior  to  the  Rolandic  fissure  on  the  left 
hemisphere  are  almost  identical  with  those  on  the  right,  in  every  detail. 

The  temporal  lobe  also  is  uniform  with  the  right. 

The  parietal  lobe. —  The  ascending  ramus  of  the  interparietal  sulcus  is  separated  from  the  horizontal 
and  descending  portions  by  an  anastomosing  arm  between  the  postcentral  and  superior  parietal  gyri. 
The  posterior  extremity  of  the  horizontal  limb  enters  into  a  roughly  star-shaped  formation.  The  poste- 
rior portion  of  the  second  temporal  gyrus,  representing  the  area  of  the  angular  gyrus,  is  a  separate  frag- 
ment; below  this  a  continuation  of  the  second  temporal  fissure  extends  backward  to  within  3.2  cm.  of  the 
longitudinal  margin. 

The  occipital  lobe  is  noticeably  larger  than  that  on  the  right.  Its  markings  are  somewhat  complex 
and  may  be  best  studied  on  the  figures  and  photographs. 

The  configuration  of  the  basal  surface  is  uniform  with  the  opposite  side. 

The  meninges  are  not  particularly  remarkable.  The  pia  is  slightly  thickened  and  the  vessels  in- 
jected. 

There  is  noticeable  occipital  asymmetry;  the  right  side  is  shorter  than  the  left,  and  points  away 
from  the  median  line. 

The  orbital  surfaces  incline  upward  to  a  marked  degree  both  postero-anteriorly  and  meso-laterally, 
thus  partly  exposing  them  to  lateral  view.  The  sulcus  pattern  here  is  a  very  simple  tri-radiate  one, 
very  similar  on  both  sides.     The  olfactory  bulbs  are  3.5  cm.  in  length,  and  not  notable  in  development. 


WAVERLET  RESEARCHES.    II. 


75 


Rt.  precentral    are   9.5   cm. 

"     postcentral    "8.       " 

L.     precentral     "    10.       " 

"      postcentral    "8.       " 

The  markings  on  the  hemispheres  are  very  nearly  symmetrical.  There  is  lack  of  development  of 
both  frontal  and  parietal  cortex;  possibly  involving  the  former  to  a  greater  degree. 

The  frontal  lobes  are  very  pointed  at  the  extreme  pole  and  are  made  up  of  only  two  convolutions. 
The  superior  is  somewhat  narrower  than  the  inferior  and  is  marked  with  short,  oblique  fissures,  and 
triangular  depressions.  The  Island  of  Reil  is  exposed  on  both  sides:  somewhat  more  on  the  left  than 
right.  At  the  base  of  the  frontal  gyri,  and  separating  them  from  the  precentral  convolutions  on  either 
side  are  short,  deep,  transverse  sulci,  which  resemble  the  sulcus  cruciatus  of  the  dog's  brain.  In  fact  this 
specimen  in  general  contour  bears  a  rather  noticeable  similarity  to  the  brain  of  a  dog.  The  convolutional 
pattern  of  the  central  region  is  very  simple.  The  pre-  and  post-central  gyri  on  the  right  are  curved  only 
at  the  genua.  The  Rolandic  fissure  on  this  side  points  occipitalward  at  its  upper  extremity,  and  nearly 
cuts  the  margin  of  the  hemisphere.  On  the  left  side  the  precentral  gyrus  is  interrupted  at  the  point 
corresponding  to  the  inferior  genu;  the  upper  knee  is  lacking.  The  Rolandic  fissure  on  this  side  is  formed 
at  its  upper  extremity  by  a  formation  with  a  convolution  of  good  width  between  it  and  the  margin  of  the 
hemisphere. 

The  horizontal  portion  of  the  right  interparietal  sulcus  is  separated  from  the  postcentral  portion 
by  an  annectant  gyrus,  between  the  superior  and  inferior  parietal  lobules.  It  curves  around  the  supra- 
marginal  and  angular  gyri,  and  seems  to  form  an  offset  to  a  portion  of  the  superior  parietal  lobule.  The 
latter  is  narrow  and  marked  with  transverse  fissures.  On  the  left  side,  the  inferior  postcentral  (descend- 
ing interparietal)  fissure  is  continuous  with  the  horizontal  interparietal. 

The  superior  post  central  is  separated  from  the  former  by  an  annectant  gyrus  connecting  the  post 
central  with  the  superior  convolution.  A  similar  opercular  formation  exists  on  the  left  as  on  the  right, 
but  it  is  made  more  complex  by  a  reduplication  caused  by  the  presence  of  an  additional  sulcus  which 
extends  with  a  single  interruption,  in  a  curved  outline  from  the  posterior  extremity  of  the  parieto-occipital 
fissure  to  the  base  of  the  second  temporal  from  the  angular  gyrus. 

The  occipital  lobes  are  very  small,  and  are  marked  by  a  few  short  fissures.  The  calcarine  fissure 
extends  upon  the  outer  surface,  ending  in  a  single  upward  curve  on  the  right,  and  in  a  T  formation  on  the 
left. 

The  temporal  lobes  are  remarkable  only  for  their  simplicity.  The  gyri  are  nearly  straight,  and 
almost  entirely  without  markings.  The  first  and  second  convolutions  are  of  good  width  and  well  rounded. 
The  third  is  somewhat  narrower  and  flattened. 

The  pyriform  lobules  are  well  developed,  the  right  apparently  more  so  than  the  left  and  are  limited 
anteriorly  by  a  well  marked  fissura  rhinica  (Turner)  (?). 

The  markings  on  the  base  of  the  brain  are  as  singularly  symmetrical  as  they  are  on  the  upper  and 
lateral  surfaces. 

The  mesial  surfaces  are  not  described  because  the  hemispheres  were  not  separated. 

d)  Microscopic  Examination. 

The  total  brain  sections  stained  by  the  Weigert  myelin  sheath  method  permit  the  observation  of  a 
marked  gliosis  in  the  white  matter  in  the  frontal  region,  especially  about  the  vessels.  In  places  the  cel- 
lular gliosis  is  general  and  marked  and  in  particular  there  is  an  abundance  of  spider  cells  in  the  subpial 
region.  Satellitosis  is  found  in  addition  to  the  above  mentioned  cellular  gliosis  and  in  certain  areas 
farther  back  in  the  frontal  region  (sections  #  146-151)  there  appears  to  be  a  particular  degree  of  satellitosis 
about  the  cells  in  the  lenticular  nucleus.     Also  in  this  posterior  portion  of  the  frontal  region,  the  gyri 


76  SOUTHARD  AND  TAFT. 

begin  to  show  a  more  marked  thinning  of  their  cell  layers  than  is  found  farther  forward.  The  mesial 
surface  of  the  uncus  of  both  sides  and  the  basal  tissues  lying  between  show  a  marked  subpial  gliosis.  Large 
cells  were  demonstrated  in  the  appropriate  region  about  the  ventricle  and  there  was  a  marked  subepen- 
dymal gliosis  with  pigmented  glia  cells  and  certain  la^ge  round  cells.  These  findings  were  especially 
noted  from  the  mesial  angle  of  the  thalamus. 

Practically  no  areas  fail  to  show  general  cellular  gliosis  but  thinning  of  the  cell  layers  is  shown  in 
addition  to  that  mentioned  above  for  the  frontal  areas  (sections  #  156-186)  also  in  the  parietal  areas 
(sections  #331  -356).  The  tapetum,  optic  radiations  and  longitudinal  bundles  are  intact.  The  tissue  per- 
mitted the  employment  of  Van  Gieson's  stain  which  demonstrated  the  subpial  gliosis  especially  well,  as 
also  a  perivascular  gliosis  in  many  places,  with  lymph  spaces  apparently  containing  glia  cells  (no  exudate 
is  present  in  any  area  studied).  The  stem  of  the  olfactory  bulb  is  found  infiltrated  with  amyloid  bodies. 
There  was  a  slight  focal  thickening  of  the  intima  in  the  basilar  artery. 

The  blood  vessels  of  the  white  matter  appear  numerous  and  there  is  a  good  deal  of  perivascular 
gliosis.     No  abnormality  of  vessel  walls  is  anywhere  shown. 


e)     Anatomical  and  Histological  Summary. 

The  gyri  are  everywhere  narrow  —  about  0.8  cm.  at  their  summits  —  and  simple  in  arrangement. 
The  primary  and  secondary  sulci  are  of  ordinary  depth,  not  complicated  by  collaterals,  and  their  walls, 
as  a  rule,  are  not  approximated  at  the  summits,  though  the  sulcal  floor  is  not  exposed. 

The  frontal  lobes  are  small,  and  pointed  at  the  anterior  poles;  the  orbital  lobes  lie  in  a  more  or  less 
vertical  plane.     The  markings  are  notably  uniform  on  both  sides. 

The  temporal  lobes  are  comparatively  large  and  are  very  simply  convoluted. 

The  parietal  lobes  present  a  greater  diversity  of  sulcation  than  any  other  part  of  the  brain.  The 
pattern  of  the  two  sides  varies  considerably.     This  is  described  in  detail  in  another  place. 

The  occipital  lobes  are  quite  at  variance  in  size,  the  right  being  considerably  shorter  than  the  left. 
A  deep  transverse  sulcus  about  midway  between  the  parieto-occipital  fissure  and  the  tip  of  the  occipital 
lobe  forms  a  relatively  large  operculum  and  seems  to  account  for  the  occipital  shortening.  This  lack  of 
uniformity  in  the  size  of  the  occipital  lobes  is  plainly  seen  on  the  basal  surface.     (See  illustration). 

The  brain  was  not  divided  longitudinally  between  the  hemispheres  and  consequently  a  detailed 

examination  of  the  mesial  surfaces  was  not  made. 

Angle  of  Rolando  with  long  fissure,  right  =  53° 
«        «         «  u        «         «        ieft     =  530 

Temporal  tip  —  frontal     pole  =    3.1  cm. 
"  "       occipital      "    =  10.3  cm. 

There  are  varying  degrees  of  satellitosis  nowhere  marked  in  the  cortex,  but  rather  more  extreme  in 
degree  in  the  basal  gray  matter. 

The  cortex  averages  about  3  cm.  in  thickness. 

The  cortical  cell-supply  seems  somewhat  reduced  in  amount,  especially  in  the  frontal  and  parietal 
lobes.  Betz  cells  prominent.  The  lack  seems  to  be  mainly  in  the  outer  layers  of  medium  sized  and 
large  pyramids  —  possibly  at  times  the  inner  layer  of  large  pyramids. 

There  is  considerable  subpial  gliosis  throughout.  This  is  particularly  true  on  the  base  of  the  brain 
between  the  crura  cerebri  and  the  base  of  the  olfactory  trigone,  especially  in  the  tempero-frontal  angle, 
where  the  glia  network  is  infiltrated  with  amyloid  granules. 

There  is  also  considerable  subependymal  gliosis  —  both  cellular  and  fibrillar  with  pigment  in  the 
glia  cells.    This  is  confined  mainly  to  the  opposed  surfaces  of  the  optic  thalamus. 


WAVERLEY   RESEARCHES.    II.  77 

Synopsis  of  Findings  in  Case  IV. 

a)  Clinical. 

Case  IV,  like  Case  III,  is  a  Danvers  State  Hospital  case.  The  patient,  M.  S.,  stated  to  be  62  years 
of  age  at  death,  September  27,  1911,  was  under  hospital  observation  only  from  July  26th  to  her  death. 
The  patient  was  an  old  almshouse  case  (Salem  and  Beverly). 

Physically  on  admission  the  patient  was  4'  8j"  tall,  and  weighed  111  pounds,  with  arteriosclerosis, 
slightly  enlarged  liver,  teeth  absent,  albuminuria,  impairment  of  vision  and  hearing,  thick  speech,  and  a 
tic  of  the  right  side  involving  head  and  shoulder. 

The  meagre  history  of  the  patient  indicates  that  she  was  of  old  American  stock.  She  had  been 
regarded  for  the  twenty-eight  years  during  which  she  had  been  under  almshouse  observation,  as  feeble- 
minded. She  was  not  selfsupporting  although  she  would  work,  receiving  a  dollar  or  a  dollar  and  a  half, 
for  a  week  or  more,  ranging  up  to  two  or  three  months.  At  the  end  of  her  employment,  she  would  leave 
with  her  clothes  tied  up  in  a  bundle  covered  by  a  cloth.  Whenever  the  patient  appeared  upon  the  street, 
she  attracted  much  attention  and  had  a  crowd  of  small  boys  following  her.  The  tic  observed  at  the 
hospital  was  apparently  of  long-standing  and  it  is  said  that  the  twitching  was  more  noticeable  when  the 
patient  was  pleased. 

Shortly  before  admission  to  Danvers  the  patient  had  become  untidy.  After  admission,  the  patient 
complained  of  headaches,  was  at  times  restless,  was  markedly  amnesic;  did  not  know  the  date  or  her 
whereabouts,  and  her  attention  was  hard  to  obtain.  Patient  apparently  reacted  to  auditory  and  visual 
hallucinations.  She  said  she  had  seen  little  women  sit  on  her  knees  and  that  they  had  blue  eyes  and  red 
hair. 

b)  Autopsy. 

Body  of  a  well  developed,  well  nourished,  white  female  141  cm.  in  length.  Rigor  mortis  present 
everywhere.  Skin  smooth,  hair  brown,  rather  thin.  Pupils,  right  6  mm.,  left  5  mm.  No  teeth  on 
either  jaw.     No  glandular  enlargements.     No  decubitus.     Tibial  crests  smooth.     Face  asymmetrical. 

Ventral  Section. —  Panniculus  over  thorax  .8  cm.,  over  abdomen  near  umbilicus  2  cm.  Muscle 
good  color.  Omentum  extends  to  umbilicus,  moderately  filled  with  fat.  Lower  border  of  liver  extends 
8  cm.  below  ensiform,  lower  border  of  stomach  extends  6  cm.  below  ensiform.  Few  adhesions  between 
omentum  and  right  parietal  peritoneum.  Adhesions  about  spleen.  Appendix  retrocedent,  lies  over 
brim  of  pelvis  5  cm.  in  length,  mesentery  throughout.  Peritoneal  mesentery  lymph  nodes  slightly 
enlarged,  no  fluid  in  abdominal  or  pelvic  cavities.  Uterus  in  right  side  of  pelvis.  Diaphragm  arches 
to  4th  interspace  left,  to  4th  interspace  right.  Sternal  bone  marrow  well  colored.  Internal  mammary 
arteries  are  not  sclerosed. 

Thorax. —  Left  lung  adherent  along  entire  posterior  region.  Adhesions  in  right  lung  lie  between 
middle  and  lower  lobes  and  pericardium,  and  between  the  upper,  middle  and  lower  lobes.  Apex  free. 
No  fluid  in  the  pleuric  cavity.  Anterior  edges  separated  by  2.5  cm.  Precordia  exposed.  Pericardium 
contains  2.5  cc.  of  clear  straw  colored  fluid. 

Heart. —  Greatest  width  10  cm.,  greatest  thickness  8  cm.  Epicardium  contains  a  small  amount  of 
fat.  Over  the  right  ventricle  is  a  milk  patch  slightly  irregular  in  outline,  approximately  2  cm.  in  diameter. 
Superficial  vessels  slightly  tortuous.     Heart  contains  fluid  blood.     Weight  225  grams. 

Measurements:     T.V.  12  cm.     P.V.         7  cm.         M.V.      8.5  cm. 
A.V.     7  cm.     L.V.     1.3  cm.        R.V.  5  cm. 

Endocardium  grey,  thickened,  aortic  valve  shows  slight  thickening  at  line  of  attachment  of  cusps, 


78  SOUTHARD  AND  TAFT. 

mitral  valve  thickened  along  border.  Tricuspid  slightly  thickened,  pulmonary  lies  flat  against  wall  and 
shows  no  thickening.  Interauriculus  septum  not  intact.  Foramen  ovale  is  patent  but  is  functionally 
closed.     Coronaries  are  free  from  sclerosis.     Arch  of  the  aorta  smooth. 

Lungs. —  Left  lung  weight  345,  adhesions  between  upper  and  lower  lobes.  Upper  lobe  air  containing 
throughout,  a  small  fibrous  scar  at  the  apex.  On  section  posterior  portion  darker  but  crepitant.  Lower 
lobe  deep  red  mottled  in  lower  portion,  floats  in  water.  Bronchi  in  lower  lobe  congested,  upper  lobe 
nothing  of  note. 

Right  lung  weight  325,  adhesions  between  upper  and  middle  lobes,  air  containing  throughout. 
Small  scar  on  anterior  surface  near  apex.  Upper  lobe  pale,  lower  lobe  slightly  congested;  lungs  float  in 
water.     Bronchi  slightly  congested.     Bronchial  lymph  nodes  not  enlarged. 

Abdomen:  Spleen. —  Weight  50  grams.  Measures  9.5  X  5  X  1.5  cm.  Capsule  grey,  slightly 
wrinkled.     On  section  soft,  mottled.     Trabeculae  and  Malpighian  bodies  distinct. 

G astro-intestinal  Tract:  Stomach. —  Lesser  curvature  20  cm.,  greater  curvature  26  cm.  Stomach 
filled  with  about  100  cc.  of  thick  yellow  mucus.  Mucous  membrane  slightly  congested,  rugae  distinct,  no 
hemorrhages  of  ulcers. 

Intestines  filled  with  a  pale  yellow  fluid,  fecal  matter  and  mucus.  Intestines  thin  walled  throughout. 
Slight  congestion  of  duodenum  and  jejunum.  Peyer's  patches  not  enlarged,  no  hemorrhages  or  ulceration. 
Mucus  membrane  of  colon  slightly  congested,  no  hemorrhages  or  ulcers. 

Liver. —  975  grams,  20  X  20  in  quadrate  lobe  X  13  in  left  lobe,  5  cm.  in  thickest  portion.  Border 
well  rounded,  on  anterior  surface  of  quadrate  lobe  near  upper  border  are  three  furrows  3.5  cm.  in  length. 
On  section  brownish,  lobulation  distinct  not  friable. 

Gall  Bladder. —  Filled  with  dark,  green  brown  bile. 

Pancreas. —  13  cm.  long  by  2.5  cm.  in  width. 

Adrenals. —  Right  adrenal  weighs  4.8  grams,  left  adrenal  weighs  5  grams.     On  section  firm. 

Kidneys. —  Right  kidney  weighs  110  grams,  measures  10.5  X  5  X  3  cm.  Capsule  strips  readily,  cor- 
tex pale,  .7  cm.  Vessels  slightly  injected.  Pyramids  slightly  more  congested  than  cortex.  On  section 
substance  bulges  slightly  beyond  capsule.  Left  kidney  weighs  135  grams,  measures  11  X  5.5  X  3.5  cm. 
Pale,  otherwise  like  the  right. 

Bladder. —  Not  unusual.     Retroperitoneal  lymph  glands  slightly  enlarged  and  darker  than  usual. 

Neck  Organs:  Oesophagus.—  Nothing  of  note. 

Thyroid. —  Fairly  symmetrical.     Weight  12  grams.     Left  lobe  a  little  more  compact  than  right  lobe. 

Larynx,  Tongue,  and  Tonsils. —  Nothing  of  note. 

Pelvic  Organs. —  External  os  of  uterus  was  closed,  canal  filled  with  mucilaginous  secretion.  Uterus 
atrophied,  shortening  of  right  broad  ligament  and  is  adherent  to  ovary  on  this  side. 

Ovary  is  atrophied,  left  tube  apparently  normal. 

Rectum,  nothing  of  note. 

Head. —  Calvarium  dense,  measures  frontal  1  cm.,  temporal  .3  cm.,  occipital  .8  cm. 

Large  amount  of  diploe.     Scalp  not  unusual. 

Dura  mater  not  adherent  to  calvarium,  slight  thickening  in  frontal  portion. 

Few  adhesions  dura  and  pia  over  vertex  and  along  longitudinal  sinus.  Few  adhesions  between  tip 
of  temporal  lobes  and  dura.  Lateral  sinus  of  left  side  contains  liquid  blood,  right  side  is  filled  with  a 
firmly  adherent  clot.     Pituitary  soft. 

Right  ear  drum  thickened  with  one  small  perforation  of  the  drum.     Left  slightly  thickened. 

Pia  Mater  slightly  thickened  notably  over  vessels  over  vertex. 

Pons  and  cerebellum  weigh  125. 

Brain  firm,  with  no  marked  atrophy  of  convolutions.  Slight  flattening  in  parietal  region  of  right 
side,  left  hemisphere  appears  well  rounded.     Ependyma  free  and  smooth,  no  sclerosis  in  basal  vessels. 

Brain  weight  1215  grams. 


WAVERLEY   RESEARCHES.    II. 


79 


Anatomical  Diagnosis. 


Well  nourished. 

Rigor  mortis. 

Unequal  pupils. 

Asymmetry. 

Chronic  peritonitis. 

Chronic  perisplenitis. 

Enlarged  mesenteric  lymph  nodes. 

Uterus  in  dextraposition. 

Chronic  adhesive  pleuritis  of  left  lung. 

Chronic  epicarditis. 

Chronic  endocarditis. 

Chronic  aortic  and  mitral  endocarditis. 


Fibrous  scars  at  apices  of  both  lungs. 
Acute  bronchitis  left. 
Small  spleen. 
Acute  gastritis. 
Acute  nephritis. 

Enlarged  retroperitoneal  lymph  nodes. 
Uterus  and  ovaries  atrophic. 
Calvarium  dense. 
Perforation  of  right  ear  drum. 
Slight  chronic  pachymeningitis. 
Slight  chronic  leptomeningitis. 
Brain  weight  1215  grams. 


c)     Special  Anatomical  Description  of  Brain. 


After  preservation  in  formaldehyde,  the  following  further  description  of  brain  was  made:  — 

The  brain  is  dolichocephalic  in  type.  There  is  slight  asymmetry  particularly  at  the  poles,  the  left 
in  each  case  being  more  pointed,  and  the  right  occipital  tip  points  away  from  the  median  line  in  a  slight 
degree. 

The  pia  is  moderately  thickened,  and  its  vessels  injected.  There  are  many  arachnoid  villi  along  the 
superior  longitudinal  fissure.  The  convolutions  throughout  are  rather  narrow,  but  fairly  well  rounded, 
and  moderately  complex.     There  is  slight  opening  of  the  sulci  throughout. 

The  primary  sulci  of  the  frontal  lobe  are  not  clearly  defined.  The  first  can  be  traced  with  some 
difficulty,  the  line  being  broken  and  irregular.  On  the  left  it  is  interrupted  by  three  annectants;  on  the 
right  the  walls  interdigitate  in  a  way  to  make  it  unclear.  The  remainder  of  both  lobes  is  marked  by 
generally  transverse  convolutions. 

The  precentral  gyrus  is  continuous  on  the  right;  on  the  left  it  is  cut  across  by  the  first  frontal  sulcus. 
The  postcentral  sulcus  is  very  narrow.  At  about  midway  its  length  an  annectant  connects  it  with  the 
inferior  parietal  lobule  on  both  sides.  The  fissure  of  Rolando  on  both  sides  forms  little  less  than  a  right 
angle  with  the  superior  longitudinal  fissure.  Their  upper  extremities  cut  the  superior  margin,  and  extend 
upon  the  mesial  surface.  The  lower  extremity  on  the  left  is  separated  from  the  fissure  of  Sylvius  by  the 
convolution  forming  the  operculum;  on  the  left  it  cuts  through  the  operculum  and  extends  into  the 
Sylvian  fissure. 

The  convolutions  of  the  parietal  lobes  are  narrow,  and  complex  with  very  slight  separation  of  their 
summits.  On  the  right  the  parts  of  the  interparietal  sulcus  are  continuous;  on  the  left  they  are  inter- 
rupted by  annectants  and  all  three  are  separate. 

The  occipital  lobes  are  not  remarkable  except  for  the  slight  asymmetry  already  noted. 

(Mesial  surfaces  are  not  photographed.) 

The  only  feature  of  the  base  of  the  brain  worthy  of  note  is  the  asymmetry  of  the  pyriform  lobules. 
The  right  is  larger  and  considerably  more  prominent  than  the  left. 

The  frontal  sections  show  both  lateral  ventricles  much  dilated,  except  in  the  descending  horns;  the 
optic  thalamus  and  the  horizontal  portion  of  the  caudate  nucleus  are  considerably  flattened.  The 
subiculum  gyrus  hippocampi  also  is  much  flattened  and  shrunken. 

The  cerebellum  is  notable  only  for  the  apparent  lack  of  uniformity  between  the  two  dentate  nuclei. 


80  SOUTHARD  AND  TAFT. 

d)  Microscopic  Examination. 

From  the  notes  of  a  partial  microscopic  examination,  the  following  is  abstracted :  — 

The  left  and  right  prefrontal  areas  exhibit  a  marked  gliosis  with  the  appearance  of  a  great  numerical 
increase  of  cells  in  all  layers.  Many  of  these  cells  are  of  a  type  best  described  as  shadow  cells.  The 
plexiform  layer  shows  coarse  glia  fibers.     The  remainder  of  the  frontal  region  exhibits  identical  changes. 

In  the  white  matter  underlying  both  the  left  and  right  precentral  gyri,  there  were  many  ganglion 
cells  largely  of  the  fusiform  type  ordinarily  found  in  the  undermost  layer  of  the  cortex.  Although  there 
were  numerous  corpora  amylacea  in  the  white  matter,  there  was  no  gliosis  and  there  was  no  alteration 
in  blood  vessels.  The  cortex  of  this  region  showed  a  slight  degree  of  satellitosis  with  a  slight  subpial 
gliosis.  There  appeared  to  be  a  focal  loss  of  nerve  cells  effected  in  various  places  of  the  laminae,  except 
the  layer  of  small  pyramids.  It  is  estimated  that  many  Betz  cells  are  smaller  than  normal.  Their 
protoplasm  is  granular  and  there  is  marked  increase  of  yellow  pigment.  There  are  frequent  shrunken 
cells  and  shadow  cells  in  all  layers.  The  postcentral  regions  of  the  two  sides  are  slightly  better  off  as  to 
cell  shrinkage  than  the  precentral  gyri. 

The  intermediate  postcentral  regions  also  show  a  considerable  degree  of  subpial  gliosis  and  numerous 
corpora  amylacea.  Upon  the  right  side  there  appears  to  be  a  thinning  in  the  layer  of  large  pyramidal 
cells  upon  the  summit  of  the  gyrus  examined.  There  is  no  such  finding  upon  the  left  side.  There  is  a 
suggestion  of  increase  in  glia  cells  throughout  the  white  substance  underlying  the  intermediate  post 
central  gyri. 

There  is  a  slight  gliosis  in  the  white  matter  of  the  calcarine  areas.  Under  the  transverse  temporal 
gyri  are  numerous  dislocated  ganglion  cells  in  the  white  substance,  resembling  those  mentioned  under 
the  precentral  gyri. 

The  area  of  Broca  shows  cellular  gliosis  with  corpora  amylacea,  a  moderate  degree  of  general  nerve 
cell  atrophy  and  a  thinning  out  of  the  layer  of  internal  large  pyramids  from  the  summits  of  the  gyri 
examined.     In  the  subpial  layer  are  many  coarse  neuroglia  fibers. 

The  hippocampal  gyri,  cornu  ammonis  and  pyriform  lobules  show  an  unusual  degree  of  subpial 
gliosis  and  infiltration  of  corpora  amylacea.  There  is  also  a  gliosis  under  the  ependyma  of  the  ventricles 
sectioned  at  this  point.  There  were  a  number  of  cells  staining  palely  with  colorless  spaces  about  the 
nucleus,  including  some  shrunken  cells  with  non-staining  nuclei  and  elsewhere  were  some  examples  of 
the  shadow  cells  above  mentioned.     There  is  occasional  satellitosis  but  not  confined  to  special  laminae. 

The  spinal  cord  and  medulla  show  a  marked  fibrillar  gliosis  of  the  periphery  and  about  the  central 
canal.  The  posterior  columns  show  a  considerable  infiltration  of  corpora  amylacea.  There  appears  to 
be  a  degree  of  perivascular  infiltration  in  the  posterior  fissure. 

e)    Anatomical  and  Histological  Summary. 

The  brain  of  this  case  shows  an  atrophy  or  aplasia  of  the  type  with  flaring  sulci  suggestive  of  a  condi- 
tion in  which  the  white  matter  is  relatively  better  preserved  than  the  grey.  The  left  side  appears  slightly 
more  hypoplastic  or  atrophic  than  the  right.  The  parietal  lobes  exhibit  particularly  narrow  convolutions 
and  may  indicate  a  certain  tendency  to  microgyria.  The  left  pyriform  lobule  is  smaller  than  the  right. 
(This  appears  accordingly  not  to  be  a  case  of  cruciate  asymmetry  in  the  sense  of  case  V,  for  example.) 

Employing  the  microscopic  examination  for  the  purpose  of  determining  whether  this  case  is  one  of 
acquired  lesion,  we  find  a  marked  gliosis  with  apparent  great  numerical  increase  of  cells  in  many  layers. 
We  find  a  coarse  fibrillar  gliosis  of  the  plexiform  layer  in  places.  We  find  a  considerable  variation  in 
degree  of  gliosis  in  different  places  but  these  findings  are  consistent  enough  with  the  hypothesis  of  rela- 
tively recent  changes  in  a  subject  of  62  years. 


WAVERLEY   RESEARCHES.    II. 


81 


Likewise  we  may  logically  dispose  of  the  satellitosis  found  in  certain  places  as  well  as  the  over- 
pigmentation  of  certain  nerve  cells.  The  shrunken  nerve  cells,  so-called  shadow  cells,  are  consistent 
enough  with  the  hypothesis  of  relatively  recent  chronic  change.  In  fact,  we  should  probably  be  at  a 
loss  to  determine  whether  there  was  any  evidence  of  fundamental  change  suggestive  of  long-standing 
lesion  if  it  were  not  for  the  dislocated  ganglion  cells  in  the  white  matter  in  certain  regions.  It  is  important 
to  raise  the  question  whether  the  slight  degree  of  perivascular  infiltration  in  the  posterior  fissure  of  spinal 
cord  in  places  is  to  be  regarded  as  a  sign  of  old  syphilis.  The  suspicion  must  at  least  be  raised  in  the  case, 
although  the  data  of  Wassermann  reaction  are  not  available.  There  are  in  the  body  at  large  no  special 
signs  indicative  of  old  syphilis  (enlargement  of  mesenteric  and  retroperitoneal  lymph  nodes,  valvular 
and  parietal  endocarditis,  etc.). 

The  case  is  of  peculiar  value  in  emphasizing  the  difficulties  which  attend  a  decision  as  to  inborn  and 
acquired  lesions  in  cases  of  elderly  subjects.  Of  course  the  majority  of  the  feeble-minded  fail  to  reach  the 
sixties,  possibly  for  reasons  inherent  in  their  general  make-up.  This  case  then  must  be  used  as  a  limiting 
instance  in  our  total  larger  series. 


Synopsis  of  Findings  in  Case  V. 

a)  Clinical. 

Case  V  has  been  already  published  in  Southard's  monograph  on  dementia  praecox,  from  which  the 
following  condensed  history  is  taken: 

C.  B.  was  a  boy  of  15  when  he  was  committed  to  D.  S.  H.,  and  died  there  a  year  and  four  months 
later  of  typhoid  fever,  ulceration,  and  peritonitis.  The  mental  diagnosis  was  eventually  considered  to  be 
dementia  praecox. 

Mother  nervous  and  melancholy  during  her  pregnancy  with  this  boy;  hard  usage  and  neglect  by 
husband  complicated  the  pregnancy.  From  an  accident  to  the  boy  at  seven,  is  said  to  date  a  change  of 
character,  with  refusal  to  go  to  school,  fretfulness,  and  nervousness.  At  14  another  accident  to  back 
and  head.  An  inmate  of  a  truant  school  for  two  periods  of  three  and  two  years  respectively.  Uncle  a 
patient  at  state  farm. 

Auditory  hallucinations,  refusal  to  eat,  nervousness,  and  certain  delusions  antedated  commitment 
by  only  a  week.  (Masturbation  had  begun  four  or  five  months  before,  but  had  probably  ceased.)  In- 
somnia is  said  to  have  lasted  four  nights  after  onset.  Food  poisoned.  Passers-by  or  Indians  were  to  kill 
him  (given  to  blood-and-thunder  stories).  "Had  never  done  anything  to  gladden  America,"  "  Traitor," 
"  Going  to  be  shot."  < 

Cyanosis  of  hands;  gait  staggering  (no  Romberg) ;  right  cremasteric  reflex  not  active. 

After  eight  months'  observation  it  was  thought  that  the  patient  really  belonged  in  the  moron  or 
subnormal  group  of  defectives,  and  in  the  quasi-criminal  class.  A  little  over  11  months  after  the  delu- 
sional episode  upon  which  he  was  committed,  patient  developed  a  spell  of  disturbance  which  lasted  10 
days.  In  this  spell,  patient  was  noisy,  threatening,  profane,  denudative,  given  to  disconnected  and 
incoherent  talking,  lost  weight  and  grew  pale.  Almost  three  weeks  later  typhoid  fever  developed,  and 
death  followed  from  peritonitis. 

b)  Autopsy. 

Summary. —  Aside  from  the  typhoid  fever  lesions,  there  were  bronzing  of  skin,  unusually  small 
adrenals  (questionable  glycosuria  had  appeared  on  entrance  but  later  disappeared),  a  small  thyroid, 
slight  sclerosis  of  aorta  and  right  auricular  endocarditis;  cardiac  hypertrophy,  chronic  myocarditis, 
pleuritis,  and  pericarditis. 


82  SOUTHARD   AND  TAFT. 

The  brain  weighed  1435  grams  (over  weight  90  grams  by  Tigges'  formula).  There  is  nevertheless  a 
tendency  to  frontal  atrophy,  perhaps  more  marked  on  left  side.  Striking  anomalous  folding  of  convolu- 
tions in  both  calloso-marginal  regions  above  the  splenium;  but  on  the  left  side  the  fissuration  suggests 
acquired  lesion  rather  than  congenital  anomaly  (region  above  and  behind  the  rostrum). 


c)  Special  Anatomical  Description  of  Brain. 

After  hardening  in  formaldehyde,  the  following  further  description  of  the  brain  was  made: 

Measurements:    Length  left  hemicerebrum,  LLH,  18.      cm. 

right  LRH,  18.      cm. 

Greatest  width  W-L.,  6.5    cm. 

Rt.,  7.      cm. 

Height,  Heit  10 .  75  cm. 

Arc  frontal  pole  to  Rolando,  left,  10.      cm. 

right,         10.      cm. 
Distance  temporal  to  frontal  tip,  left,      4.5    cm. 

right,  5 .      cm. 

The  specimen  shows  the  not  unusual  frontal  and  occipital  cruciate  asymmetry,  in  which  the  frontal 
lobe,  particularly  the  most  anterior  portion,  and  the  contralateral  occipital  lobe,  are  narrower  than  their 
fellows.     In  this  case  it  applies  to  the  left  frontal  and  right  occipital  lobes. 

There  is  slight  general  clouding  of  the  pia  over  the  vertex,  somewhat  more  extreme  near  the  margin 
of  the  longitudinal  fissure.     The  pial  vessels  are  moderately  injected. 

With  the  pia  removed  the  convolutions  appear  in  general  fairly  well  rounded,  but  rather  narrow; 
their  summits  are  not  closely  approximated.     There  is  no  remarkable  lack  of  complexity. 

The  frontal  convolutions  are  distinctly  separated  from  each  other  by  longitudinal  sulci,  though  an 
annectant  connects  the  middle  of  the  first  with  the  base  of  the  second  on  both  sides.  The  third  is  notice- 
ably prominent  on  the  left. 

In  the  central  area  the  Rolandic  fissures  leave  the  superior  margin  of  the  hemisphere  at  a  right  angle. 
At  the  superior  knee  the  right  points  forward  more  than  the  left,  but  the  lower  extremities  both  end  at  a 
point  7  cm.  from  the  frontal  tip.  The  upper  extremity  of  Rolando  extends  onto  the  mesial  surface 
1.5  cm.  in  a  backward  direction  on  the  left,  0.5  cm.  perpendicularly  on  the  right.  The  post  central 
convolution  is  slightly  narrowed  in  its  upper  extremity.  In  the  parietal  lobes  the  post  central  sulcus 
forms  a  second  or  double  Rolandic  fissure.  Posterior  to  this  one  the  usual  interparietal  sulci,  with  the 
horizontal  and  descending  branch. 

The  occipital  lobes  are  small;  the  left  side  is  not  otherwise  notable,  but  on  the  right  side  the  second 
gyrus  is  narrowed  and  shrunken,  causing  a  drawing  in  of  the  surface,  a  part  of  which  is  consequently 
depressed  below  the  surrounding  area.  On  lateral  view  this  forms  a  slight  concavity  in  the  surface  of 
the  occipital  lobe. 

The  basal  surface  of  the  brain  shows  no  marked  anomalies.  The  collateral  sulcus  on  the  left  is 
interrupted  about  midway  by  an  annectant  between  it  and  the  fourth  temporal  convolution.  The 
typical  H-shaped  sulcation  on  the  orbital  surface  is  absent;  the  fissures  are  mainly  sagittal  in  direction, 
and  near  the  lateral  margin,  leaving  the  middle  orbital  gyrus  unusually  wide.  The  lateral  view  of  the 
region  shows  the  so-called  "keel-formation"  of  the  gyri  recti. 

The  mesial  surfaces  of  the  hemispheres  are  striking  particularly  on  account  of  the  unusual  similarity 
in  their  configuration.     The  cuneate  lobule  on  the  left  is  somewhat  smaller  than  that  on  the  right. 

The  corpus  callosum  is  slightly  thinned  in  its  posterior  half. 

There  is  no  middle  commissure. 


WAVERLEY   RESEARCHES.    II.  83 

Gross  frontal  sections  show  the  cortex  of  fair  and  uniform  width  throughout. 

There  is  some  apparent  atrophy  at  the  anterior  temporo-insular  junction,  which  leaves  the  adjacent 
parts   unapproximated. 

The  cavity  of  the  right  lateral  ventricle  is  larger  in  all  its  diameters  than  that  on  the  left,  although 
the  difference  is  only  moderate  in  degree. 

There  is  nothing  remarkable  about  the  basal  nuclei  or  the  subthalamic  structures. 

d)    Microscopic  Examination. 

The  Weigert-Myelin  sheath  preparations  show  good  fiber  connections  in  all  areas  examined.  Com- 
parisons were  made  with  the  drawings  in  Campbell's  "Localization  in  Cerebral  Function."  Evidences 
of  gliosis  were  as  follows:  — 

The  prefrontal  tissue  shows  a  moderate  increase  in  the  plexiform  layer,  involving  not  only  an  in- 
crease in  a  number  of  cells  but  in  the  number  of  fibrils.  There  is  no  gliosis  elsewhere.  Although  there 
are  frequent  ganglion  cells  in  the  white  matter,  there  is  no  notable  neuroglia  increase  in  this  locus.  The 
prefrontal  region  showed  occasional  bi-nucleate  neuroglia  cells  supplied  with  fibrils  in  the  plexiform  layer; 
but  there  is  no  marked  gliosis  elsewhere. 

The  same  description  fits  the  postcentral  tissue,  except  that  there  are  groups  of  satellite  cells  in 
various  layers  (right  postcentral)  as  a  rule  surrounding  the  small  nerve  cells. 

The  superior  and  inferior  parietal  regions  show  similar  glia  pictures  in  the  plexiform  layer.  From 
the  standpoint  of  gliosis,  accordingly,  the  cerebral  cortex  of  this  case  exhibits  in  all  areas,  so  far  as  ex- 
amined, a  moderate  degree  of  cellular  and  fibrillar  gliosis  of  the  plexiform  or  subpial  layer,  but  fails  to 
show  gliosis  in  other  layers,  except  in  the  specimens  examined  from  the  right  postcentral  region. 

As  against  the  neuroglia  picture,  we  may  consider  the  nerve  cell  pictures.  Of  course  the  excellent 
preservation  of  the  fiber  connections  as  above  noted  would  indicate  that  there  should  be  no  extensive 
degree  of  cell  loss.     What  has  so  far  been  found  may  be  summed  up  as  follows : 

The  prefrontal  region  (for  example,  on  the  right  side)  shows  a  suggestion  of  thinning  out  of  the  nerve 
cells  in  the  supragranular  layers;  at  the  summit  of  the  gyrus  the  cells  here  are  often  small  and  deeply 
stained. 

The  large  pyramidal  cells  of  the  infragranular  region  seem  also  thinned  out.  Similar  slight  degrees 
of  thinning  out  of  the  cells  are  found  in  the  supragranular  pyramidal  layers  of  the  precentral  region 
(upper  portion  right  side) ;  identical  findings  in  lesser  degree  in  the  postcentral  region  and  in  larger  degree 
of  the  superior  parietal  and  inferior  parietal  regions.  On  the  whole,  the  evidence  of  nerve  cell  loss  or 
absence  is  distinct  but  slight.  On  the  whole  the  supragranular  layers  appear  to  be  more  involved  in 
this  cell  loss  or  absence  than  the  infragranular  layers.  It  is  to  be  noted  also  that  no  important  degree 
of  satellitosis  accompanies  this  cell  loss,  if  we  except  the  area  examined  from  the  right  postcentral  region. 

A  common  finding  in  numerous  areas  is  the  presence  of  dislocated  ganglion  cells  in  the  white  matter. 
These  were  noted  as  frequent  in  right  upper  precentral,  right  postcentral,  right  inferior  parietal,  right 
superior  frontal,  and  right  prefrontal  areas. 

As  for  acute  changes  there  was  apparently  a  degree  of  chromatolysis  in  the  larger  cells  in  the  frontal 
region,  but  not  elsewhere. 

e)  Anatomical  and  Histological  Summary. 

Frontal  and  occipital  cruciate  asymmetry  suggest  inborn  or  very  early  acquired  lesion.  This  case 
may  well  have  been  one  of  Dementia  Praecox  grafted  upon  a  subnormal  or  moron  condition  and  the 
microscopy  is  accordingly  of  interest.  As  in  the  previous  case,  (IV),  so  here  there  are  frequent  dis- 
located ganglion  cells  in  the  white  matter.     The  gliosis  and  satellitosis  of  irregular  distribution  are  con- 


84  SOUTHARD  AND  TAFT. 

sistent  enough  with  the  hypothesis  of  acquired  lesion.  Nerve  cell  loss  might  be  interpreted  in  either 
direction  as  due  to  fundamental  absence  or  to  early  or  late  degeneration.  In  various  places,  the  supra 
granular  layers  are  subject  to  thinning  out  without  any  important  degree  of  satellitosis  (exception  right 
post  central  region).  Our  best  argument  therefore  for  inborn  lesion  is  the  dislocated  ganglion  cells  in 
the  white  matter,  with  the  thinning  out  of  cells  in  the  supragranular  layers  as  a  not  very  strong  secon- 
dary argument.  Of  course  it  has  sometimes  been  held  that  satellitosis  should  be  found  alongside  the  cell 
loss  in  Dementia  Praecox.  Special  studies  in  another  series  of  cases,  to  be  published  in  the  Trans- 
actions of  the  Association  of  American  Physicians  for  1916,  indicate,  however,  that  cell  loss  and  satellitosis 
do  not  necessarily  proceed  pari  passu  and  that,  in  point  of  fact,  in  not  infrequent  instances,  the  cell  loss 
proceeds  independently  of  reaction.  In  some  instances,  it  might  be  argued  that  the  tissues  passed  through 
a  phase  of  satellitosis  followed  by  a  phase  in  which  nothing  but  cell  loss  can  be  demonstrated.  An  argu- 
ment of  this  nature  has  been^ submitted  in  a  paper  published  in  the  above  mentioned  Transactions  for  1915. 
At  any  rate,  it  would  probably  be  agreed  by  all  that  in  Senile  Dementia  there  are  cases  in  which  nerve 
cells  slowly  disappear  without  neuroglia  reaction.  The  present  case  must  therefore  be  used  as  another 
instance  of  the  fundamental  difficulty  which  attends  a  decision  as  to  whether  a  case  is  one  of  primary  or 
secondary  amentia,  even  when  a  comparatively  full  anatomical  and  microscopic  analysis  is  available. 


Synopsis  in  Findings  of  Case  VI. 
a)  Clinical. 

1.  Physical  Examination. —  Born  in  1887;  died  Oct.  19, 1913.  Slightly  microcephalic;  tall  and 
rather  slight;  death  from  pulmonary  tuberculosis.  Further  data  are  given  in  the  description  of  the 
autopsy,  below,  in  which  the  following  features  are  of  interest  from  the  point  of  view  of  the  pathological 
anatomist.  The  number  of  scars  of  "  tissue  paper"  appearance  over  extremities,  back,  and  head,  suggested 
syphilis.  There  were  also  numerous  superficially  palpable  lymphnodes;  mal-formed  ears;  prominent 
mastoid  processes;  high  palatine  arch;  asymmetry  of  face,  especially  of  nose  and  jaw;  underdeveloped 
hands  and  genitalia;  redundant  prepuce;  absence  of  right  vocal  cord;  hypoplastic  aorta,  and  accessory 
spleens.     No  history  of  epilepsy. 

2.  Family  History. —  Unknown.  There  is  some  suspicion  of  syphilis  in  the  father,  but  the 
suspicion  has  not  been  well  established.  Patient  had  been  three  years  in  almshouse  at  Tewksbury  before 
admission  to  the  Massachusetts  School,  May  27,  1893. 

3.  Personal  Developmental  History. —  Is  said  to  have  had  measles.  At  time  of  application,  at 
6  years  of  age,  he  is  said  to  have  just  begun  to  talk,  and  as  understanding  a  good  deal  of  what  was  said 
to  him.  Patient  is  described  as  very  restless  and  nervous;  is  usually  rushing  around;  inclined  to  be 
destructive,  especially  of  cloth;  soils  and  wets  himself  several  times  a  day  and  every  night.  He  would 
spend  his  time  destroying  shirtsleeves  and  coatsleeves,  unravelling  his  stockings,  and  the  like. 

4  and  5  and  6.  School  Progress  and  Examinations.  Practical  Knowledge. —  Progress  at 
the  Massachusetts  School  was  slight.  Patient  was  placed  in  the  training  classes  but  did  not  advance 
much.  He  was  able  to  do  simple  outdoor  manual  work.  (He  could  help  to  clear  land,  use  grubhoe,  dig 
up  stones,  and  the  like,  and  was  able  to  polish  floors  and  carry  bundles.)  Was  able  to  feed  himself  with 
a  spoon  although  he  spilled  much  of  the  food.     Needed  to  be  helped  in  dressing  and  undressing. 

7.  Economic  Efficiency. —  Nil. 

8.  Social  History  and  Reactions. —  Unable  to  speak  words.  Made  curious  squeaking  attempts 
at  speech  if  people  that  he  liked  were  about  him. 

9.  Moral  Reactions. —  If  something  patient  did  happened  to  annoy  the  caretakers,  patient 
seemed  to  take  pleasure  in  their  annoyance.     Patient  had  the  typical  idiotic  grin  when  spoken  to. 


WAVERLEY  RESEARCHES.    II.  85 

10.  Psychological  Tests. —  Approximately  2.  This  case,  by  reason  of  his  aphasia  (compare  absence 
of  one  vocal  cord),  yielded  a  poorer  impression  of  his  capacity  than  was  perhaps  justified.  In  some 
respects,  patient  appears  to  have  been  above  the  rank  of  idiocy  and  to  fit  into  the  lower  grade  of  imbecility. 

Waverley  School  History. —  Patient's  tuberculosis  resisted  outoor  treatment. 


b)  Autopsy. 

Body. —  That  of  a  slenderly  built  emaciated  white  male  158  cm.  in  length.  The  skin  is  bluish  gray, 
and  abrasions  occur  over  elbows,  hands  and  shins,  irregularly.  There  are  also  quantities  of  "tissue 
paper"  scars  over  lower  legs  and  back  and  scalp  varying  in  size  from  0.8-1.5  cm.  in  diameter.  Lymph 
nodes  palpable  in  neck  and  groins.    Rigor  mortis  absent,  no  body  heat.     Decomposition  bands  in  flanks. 

The  head  is  markedly  out  of  proportion,  being  long  and  narrow  (occipitomental  56  cm.)  the  ears 
flare  and  the  measurement  from  superior  portion  of  helix  to  lobule  inclusive  is  5.5  cm.  X  4.0  cm.  from 
tragus  to  lateral  side  of  helix,  with  a  wide  and  flat  antitragus  and  a  minute  tragus.  Mastoid  processes 
unduly  prominent.  Palatine  arch  high,  teeth  in  fair  condition.  Nose  is  deflected  to  right  and  the  angle 
of  the  lower  jaw  on  this  side  is  markedly  prominent,  the  line  of  the  left  being  longer  and  the  angle  less 
noticeable.  The  hands  appear  larger  than  would  be  proportionate  with  the  arms,  and  the  finger  nails 
are  minute,  measuring  0.6  cm.  in  height  showing  evidences  of  much  nibbling  and  the  eminences  below 
the  thumb  are  absent  —  giving  the  palmar  surfaces  a  remarkably  undeveloped  appearance.  Legs  not 
notable.  Genitals:  The  scrotum  short  and  broad,  extending  in  direction  of  but  not  reaching  anal  surface. 
Penis  short  and  thick.  Prepuce  long,  glands  very  red.  No  edema;  a  decubitus  measuring  0.4  cm.  over 
sacrum  is  fairly  superficial. 

Ventral  section. —  Panniculus  nil.  Muscles  red,  peritoneum  shows  post  mortem  change.  Omeutnm 
contains  no  fat,  transverse  colon  extends  in  a  V-shape  with  apex  downward  into  pelvic  cavity.  Stomach 
14  cm.,  liter  8.0  cm.  below  costal  margin.  Spleen  free;  mesenteric  lymph  nodes  remarkable  in  size  and 
number,  some  measuring  3  cm.  in  length.  Appendix  8.0  cm.  in  length  —  has  a  mesentery  of  its  own. 
Prostate  not  enlarged,  no  free  fluid  in  the  cavity.  Diaphragm  arches  to  the  3d  interspace  on  the  right, 
the  4th  on  the  left. 

Thorax. —  Mammary  vessels  not  sclerosed,  sternum  measures  3.0  cm.  on  frontal  aspect,  5.5  cm.  on 
visceral.  Bone  marrow  of  sternum  rich  red,  smears  stained  show  excess  of  eosinophiles  and  few  giant 
cells.     No  nucleated  red  cells. 

Pleuric  cavities  obliterated  at  apices,  anterior  edges  of  lungs  overlap  in  median  line:  pericardium  not 
thickened. 

Heart. —  (No  weights  taken),  estimated  250  grams.  No  fat  in  epicardium.  Myocardium  greenish 
red  (p.  m.).  Coronaries  show  no  change.  Section  shows  right  auricle  and  ventricle  filled  with  cruor 
clot.     Myocardium  elastic,  not  friable. 

Measurements:   TV.,   13.0  cm.        P.  V.,  6.0  cm.        L.  V.,  1.0  cm. 
M.  V.,  10.0  cm.        A.  V.,  6.5  cm.        R.  V.,  0.4  cm. 

Endocardium  not  remarkable.     Some  slight  thickening  in  aortic  cusps  below  corpus  aurantii. 

Lungs. —  Not  weighed.  Over  surface  of  left  there  are  areas  which  show  as  slightly  umbilicated 
centrally,  red  edges  measuring  0.4  cm.  Cut  section  shows  a  spongy  parenchyma,  with  thickened  bronchi 
in  the  lower  portion  and  a  gush  of  yellowish  puriform  material  follows  knife  cut  at  apex.  Stained  smear 
shows  tubercle  bacilli  in  countless  numbers. 

Same  process  in  right  lung,  possibly  more  extensive.  Peribronchial  lymph  nodes  not  remarkable 
and  showed  no  areas  of  infiltration  on  section. 

Organs  of  the  neck. —  The  tongue  is  heavily  coated.  The  epiglottis  is  thick  and  yellowish  and  bathed 
in  pus.     The  aryteno-epiglottidean  folds  are  ragged  on  their  free  edges.    From  above  superior  and 


86  SOUTHARD  AND  TAFT. 

inferior  vocal  cords  appear  unequal,  and  on  section  there  are  none  on  the  right,  being  replaced  by  small 
white  nodes  which  extend  over  the  whole  cavity  of  the  larynx  above  the  cord  district.  On  the  left  a 
ventricle  is  the  only  mark  by  which  a  superior  and  inferior  vocal  cord  may  be  inferred.  Thyroid  not 
notable.  No  thymus  nor  parathyroids  seen.  Aorta  is  remarkably  narrow  (3.5  cm.  in  circumference) 
and  very  elastic. 

Abdomen. —  Spleen  not  weighed.  Estimated  weight  100  grams.  Somewhat  autolysed,  capsule 
not  thickened.  Pulp  soft,  trabeculae  and  malpighian  bodies  not  notable.  On  the  inferior  edge  two  small 
accessory  spleens  hang,  one  is  0.2  cm.,  another  0.8  cm.  in  diameter. 

Adrenals. —  Remarkably  small,  not  over  1.5  cm.  at  the  widest  part  on  cut  section. 

Kidneys. —  Not  weighed  —  estimated  200  grams.  No  perirenal  fat;  capsule  stringy  and  non- 
adherent, cortex  swells  slightly  over  capsule,  color  of  medulla  and  cortex  homogeneous  (from  p.  m.  change). 
Pelves  not  notable. 

Liver. —  Not  weighed  —  estimated  1500  grams.  Capsule  not  thickened.  Streaks  of  yellow  occur 
on  surface,  organ  friable  but  holds  its  own  weight,  inferior  edges  sharp.     No  stone  in  gall-bladder. 

Pancreas. —  Not  examined. 

G astro-intestinal  tract. —  Not  examined.     Were  deep  greenish  red  from  post-mortem  change. 

Genito-urinary  tract. —  Prostrate  not  enlarged.  Bladder  contains  some  heavy  purulent  material. 
Testis  threads  well. 

Head. —  Hair  black  and  short;  scalp  adherent.  Calvarium  is  well  supplied  with  diploe  but  has 
curious  inequalities  in  thickness;  frontal  measures  0.8-1.0  cm.,  temporal  0.2-0.8  cm.  (in  strikingly 
irregular  alternations),  occipital  0.9  cm.  The  dura  is  not  adherent  except  along  the  superior  longitudinal 
sinus,  and  is  thickened  only  along  the  middle  meningeal  distribution  and  the  convolutions  are  plainly 
seen  through  it.  Pia  mater  is  exceedingly  thin  and  delicate,  without  edema;  the  twigs  of  the  arterial 
capillaries  are  very  brilliantly  outlined.  There  are  but  two  large  veins  on  the  vertex,  these  correspond 
very  nearly  to  fissure  of  Rolando  and  are  distended.  The  hemispheres  are  apparently  equal  in  size 
with  the  exception  of  a  bilobed  occipital  lobe  on  the  right.  There  seems  to  be  no  cerebrospinal  fluid. 
The  brain  sags  on  a  board  and  tends  to  assume  a  nearly  round  mass.  The  convolutional  pattern  is 
simple  and  the  sulci  shallow,  particularly  is  this  so  on  the  right,  involving  the  motor  and  parietal  lobule, 
and  seeming  to  limit  the  frontal  pole,  the  left  parietal  lobule  having  a  more  complex  configuration  and 
the  frontal  pole  a  greater  extension.  Smear  from  this  portion  shows  striking  loss  of  nerve  cells;  and 
infiltration  of  vessel  walls  with  lymphocytes  and  polynuclear  cells. 

At  the  base. —  The  2nd  left  temporal  convolution  at  the  tip  has  a  yellow  and  denuded  look  under  the 
pia  and  is  somewhat  firmer  to  the  touch.  Question  of  tubercle.  Smear  from  this  portion  shows  cellular 
detritus.     No  organisms. 

The  denuded  area  on  the  right  temporal  tip  is  artefact.  The  basal  vessels  are  slightly  hazy  but  no 
buds  nor  abnormal  branching  of  arteries  seen.  The  pia  at  base  binds  the  3rd  and  4th  nerves  to  the 
anterior  perforated  space.  Cerebellum  slightly  softened,  the  olivary  bodies  are  fairly  firm  as  are  the  occi- 
pital tips.  Remainder  of  brain  (with  exception  noted)  fairly  normal  in  consistence.  Pituitary  pigmented 
on  section.  Ganglions  negative.  Petrous  portion  temporal  bone  thick.  Left  ear  drum  has  a  hole 
0.3  cm.  in  diameter  in  its  center  with  white  and  indurated  edges,  and  smear  shows  tubercle  bacilli.  Right 
negative.  Optic  nerves  show  brilliant  injection  of  retinal  arteries  with  question  of  blurred  outline  of 
nerve  head.  There  are  irregularities  in  bone  in  the  middle  meningeal  distribution.  Brain  weight,  1130 
grams. 

Cord. —  Not  notable. 


WAVERLEY  RESEARCHES.    II. 


87 


Anatomical  Diagnosis. 


Emaciation. 

Abrasions  over  extremities. 

?Syphilitic  scars  over  extremities  and  back. 

Scars  over  head. 

Palpable  lymphnodes  (superficial). 

Dolichocephalic  head. 

Malformed  ears. 

Prominence  of  mastoid. 

Palatine  arch  high. 

Asymmetry  face  (nose  and  jaw). 

Nails  nibbled  below  the  mid  line. 

Hands  undeveloped. 

Redundant  prepuce. 

Genitals  undeveloped. 

Decubitus  superficial  (sacral). 

Gastroptosis. 

Splanchnoptosis. 

Lymphnodes  large  and  prominent  (rever- 
sion?). 

Chronic  fibrous  pleuritis. 

Pulmonary  tuberculosis. 

Slight  chronic  fibrous  endocarditis  (aortic 
valve). 


Tuberculous  epiglottis. 
Tuberculous  aryteno-epiglotidean  folds. 
?Aplasia  vocal  cords. 
?Tuberculosis  of  vocal  cords. 
Small  aorta. 
Autolysis  of  spleen. 
Accessory  spleens. 
Small  adrenals. 

Slight  acute  parenchymatous  nephritis. 
Cystitis. 

Calvarium  unequal  in  thickness. 
Calvarium  brittle. 
Focal  chronic  pachymeningitis. 
Slight  anomaly  right  occipital  tip. 
?Hydrocephalus. 

Inequality  of  convolutional  pattern,  particu- 
larly right  side. 
Slight  basal  leptomeningitis. 
Tuberculous  ulcer  left  ear  drum. 
Pigmentation  of  pituitary. 
?Choked  discs. 
Brain  weight:   1130  grams. 


c)     Special  Anatomical  Description  of  Brain. 


The  brain  is  symmetrical;  the  frontal  lobes  small  and  pointed;  the  occipital  lobes  short,  and  their 
tips  point  away  from  the  median  line. 

The  pia  is  generally  slightly  thickened,  with  numerous  arachnoid  villi  along  the  superior  longitudinal 
fissure  on  both  sides.     The  pial  vessels  are  moderately  injected,  including  the  capillaries. 

The  convolutions  throughout  are  broad,  well-rounded,  and  there  is  a  noticeable  lack  of  complexity. 

In  the  right  frontal  lobe,  the  first  convolution  is  much  narrower  than  the  second  or  third;  the  two 
latter  are  not  clearly  defined,  and  are  very  scantily  fissured.  On  the  left  there  are  apparently  four 
longitudinal  divisions,  and  each  is  somewhat  more  complex  than  on  the  right.  The  third  left  frontal 
is  not  remarkable. 

The  central  convolutions  are  of  good  width,  and  well-rounded.  The  precentral  is  connected  about 
midway  its  length  with  the  base  of  the  second  frontal  by  a  recurved  annectant.  The  postcentral  con- 
volution is  narrow  at  its  upper  extremity  on  both  sides,  and  again  at  the  junction  of  the  middle  and  lower 
thirds  on  the  right.  The  fissure  of  Rolando  forms  little  less  than  a  right  angle  with  the  superior  longi- 
tudinal fissure.  Its  upper  extremity  cuts  the  superior  margin  on  the  left  and  on  the  right  extends  well 
over  on  the  mesial  surface.  The  lower  extremity  cuts  the  operculum  on  both  sides  and  is  lost  in  the 
Sylvian  fissure. 

The  parietal  lobes  are  marked  by  a  very  irregular  pattern.  The  sulci  are  generally  arranged  in  a 
transverse  direction.  The  superior  parietal  lobules  are  broad;  the  right  one  somewhat  more  so  than  the 
left,  and  both  present  very  few  secondary  fissures. 

The  sulcal  pattern  of  the  temporal  lobes  is  rather  irregular;  on  the  right  the  superior  gyrus  is  narrow 


88  SOUTHARD  AND  TAFT. 

and  loosely  convoluted.  The  superior  sulcus  is  distinct  and  complete.  The  second  convolution  is  broad 
with  very  few  fissures,  and  these  are  confined  mainly  to  the  posterior  part  of  the  gyrus.  On  the  left  the 
limiting  sulci  are  indistinct,  but  on  the  whole  the  fissure-complex  is  less  simple. 

Of  the  mesial  surfaces,  the  right  is  more  complex;  the  cuneate  lobule  is  larger  and  presents  more 
fissures.  The  right  calloso-marginal  fissure  is  complete  from  its  subrostral  origin  to  the  marginal  ex- 
tremity, while  on  the  left  it  is  interrupted  several  times  by  annectants.  The  corpus  callosum  is  thin 
throughout  its  entire  length. 

The  most  evident  peculiarity  of  the  orbital  surfaces  is  the  difference  in  width  of  the  gyri  recti.  The 
right  is  nearly  twice  as  broad  as  the  left,  and  extends  beyond  the  median  line  to  the  extent  that  its  mid- 
point corresponds  in  position  to  that  of  the  optic  chiasm. 

The  pyriform  lobules  are  nearly  uniform  in  size;  the  collateral  fissure  is  continuous  with  the  fissura 
rhinica  on  the  right,  but  fails  to  join  on  the  left.  Altogether  the  left  temporal  lobe  presents  the  appear- 
ance of  better  development  than  the  right. 

Frontal  sections  show  no  focal  lesions.  The  cortex  is  of  fair  width,  and  the  white  matter  compara- 
tively small  in  amount.  All  the  sulci  in  the  temporal  lobe  are  deep,  and  the  gyri  narrow,  finger-like 
processes. 

There  is  no  enlargement  of  the  ventricles,  nor  other  anomaly  apparent. 

d)     Microscopic  Examination. 

From  the  partial  microscopic  examination,  the  following  is  abstracted: 

The  findings  in  numerous  areas  yield  a  somewhat  general  picture.  There  is,  as  a  rule,  an  increase 
of  neuroglia  cells  in  the  white  substance.  Even  the  vessels  are  lined  by  an  accumulation  of  neuroglia 
cells .  There  is  a  considerable  satellitosis  in  all  layers,  including  the  plexif orm  layer,  but  there  is  no 
tendency  to  an  excess  of  gliosis  in  the  plexiform  layer.  There  is  a  tendency  to  decrease  of  nerve  cells 
so  far  as  qualitative  estimate  can  suffice  in  the  diagnosis  in  most  areas.  The  frontal  areas  show  a  smaller 
degree  of  scarcity  of  cells  than  numerous  other  areas.  On  the  whole,  the  qualitative  estimate  of  neuroglia 
cell  increase  rather  indicates  that  the  left  side  is  more  affected  than  the  right  (for  example,  left  insula, 
left  superior  parietal,  left  pyriform  lobule,  left  transverse  temporal). 

The  findings  of  particular  interest  are  as  follows:  —  First,  rod  cells  in  the  cortex  of  the  right  upper 
post  central  region,  a  region  which  also  shows  a  moderate  degree  of  cellular  gliosis  in  the  white  matter; 
but  this  latter  gliosis  was  characterized  by  the  presence  of  a  great  many  glia  nuclei  of  unusual  shape. 
The  area  showed  very  general  thinning  out  of  the  cells  in  all  layers,  particularly  at  the  summit  of  the 
gyrus.  Frequently  cells  are  found  with  an  appearance  of  degeneration.  Rod  cells  are  also  found  in 
the  right  pyriform  lobule. 

Secondly;  the  finding  of  one  large  vessel  in  the  right  precentral  region  surrounded  by  a  relatively 
heavy  collection  of  lymphocytes;  other  vessels  show  numbers  of  green  pigment-laden  phagocytes. 
This  area  shows  considerable  satellitosis  in  all  layers;  the  satellite  cells  are  particularly  noteworthy  about 
the  large  pyramidal  cells.  There  is  an  increase  in  neuroglia  cells  in  the  plexiform  layer  with  a  focal 
tendency.  Of  course  in  connection  with  a  suspicion  of  brain  syphilis,  which  we  may  consider  proper  to 
raise  in  connection  with  the  lymphocytosis  above  noted,  especial  attention  was  given  to  the  observa- 
tion of  other  foci  of  lymphocytosis.  Several  other  examples  of  infiltrated  blood  vessels  were  found  in 
the  frontal  region  and  with  a  tendency  to  accretions  in  the  vertical  region. 

e)  Anatomical  and  Histological  Summary. 

This  brain  of  simple  construction  (1130  grams)  is  comparatively  symmetrical.  Its  corpus  callosum 
is  thinned  throughout.  The  white  matter  of  the  centrum  semi  ovale  is  comparatively  small  in  amount. 
It  does  not  appear  that  the  ventricles  are  enlarged.     Microscopically  once  more  we  discover  a  marked 


WAVERLEY   RESEARCHES.    II. 


89 


gliosis,  with  considerable  satellitosis  corresponding  with  a  certain  decrease  of  nerve  cells,  if  we  may  judge 
qualitatively  of  such  loss.  On  the  whole  the  left  side  is  slightly  more  affected  than  the  right.  We  raised 
the  hypothesis  in  Case  IV  as  to  old  syphilis,  basing  our  suggestion  upon  the  presence  of  the  effects  of 
perivascular  infiltration  in  posterior  fissure  of  the  spinal  cord.  If  we  follow  the  same  line  of  argument 
in  Case  VI,  we  should  call  attention  to  the  effects  of  lymphocytosis  about  a  large  vessel  in  the  right  pre- 
central  region.  The  presence  of  rod  cells  in  the  cortex  of  the  right  upper  post  central  region  as  well  as 
in  the  right  pyriform  lobule  may  perhaps  be  regarded  as  evidence  running  somewhat  in  the  same  direc- 
tion. These  rod  cells  are  characteristic  of  certain  cases  of  General  Paresis,  although  neuropathologists 
do  not  customarily  make  a  diagnosis  of  brain  syphilis  upon  the  presence  of  rod  cells.  It  may  be  that 
both  the  focal  lymphocytosis  and  the  occurrence  of  rod  cells  are  based  upon  some  other  condition  than 
syphilis,  but  at  all  events,  the  lesions  are  of  an  acquired  nature  and  go  to  indicate  the  presence  of  at  least 
a  slight  degree  of  active  chronic,  inflammatory  processes.  It  is  possible  to  think  of  tuberculosis  as  re- 
sponsible for  the  lymphocytosis  and  it  may  be  for  the  rod  cell  deposits,  since  this  case  showed  widely 
distributed  tuberculosis,  pulmonary,  epiglottis,  vocal  cords,  left  ear  drum,  etc.  A  review  of  the  anatomi- 
cal diagnoses  in  the  case  will  show  the  presence  of  numerous  stigmata. 


Synopsis  of  Findings  in  Case  VII. 
a)  Clinical. 

1.  Physical  Examination. —  At  15  years  of  age,  patient  was  five  feet  tall  and  weighed  97§  pounds. 
She  was  born  May  5, 1888,  and  died  March  17, 1914.  Patient  is  described  as  undersized,  poorly  nourished, 
anaemic,  slightly  deaf;  as  having  a  small  cranium,  with  circumference  of  19f  inches,  and  cephalic  index 
of  84.  The  face  was  asymmetrical,  the  eyes  closely  set,  the  teeth  irregular,  the  palate  high,  and  narrow 
arch.  From  the  autopsy  report,  given  in  full  below,  the  following  features  are  culled:  Absence  of  axillary 
hair,  anomalous  distribution  of  pubic  hair,  rudimentary  left  nipple,  anomaly  of  toes,  deflection  of  nose 
to  left,  dental  ridges  (mal-nutrition?),  ovaries  very  large,  anomaly  of  kidney;  anomaly  of  sympathetic 
gangliated  cord. 

2.  Family  History. —  Patient's  father  was  born  in  New  York  City,  of  French  extraction;  the 
mother  was  born  in  England.  The  father  was  37  years  old  at  the  birth  of  the  child;  the  mother  was  42, 
and  had  had  four  children  before  the  birth  of  the  present  case.  Three  of  the  children  had  died  before 
1893:  two  girls,  described  as  dying  of  marasmus,  and  one  boy  as  dying  of  croup  at  the  age  of  5  years. 
It  is  stated  that  there  was  no  deformity  of  body  or  mental  deficiency  in  the  other  children.  The  mother 
is  described  as  never  having  been  very  strong,  and  as  subject  to  fainting  fits.  She  is  stated  to  have  been 
in  excellent  health  until  the  sudden  death  of  the  boy  above  mentioned,  which  death  took  place  when  she 
was  7  months  pregnant  with  the  present  patient.  The  mother  states  that  she  fell  off  a  small  box  24  hours 
before  delivery,  and  that  the  patient  was  born  at  8  months.  An  aunt  of  the  patient,  the  mother's  oldest 
sister,  is  stated  to  have  become  paralyzed  at  the  age  of  24  years,  and  remained  in  this  paralyzed  condition 
until  her  death,  at  42,  of  consumption. 

3.  Personal  Developmental  History.—  The  patient  was  carried  on  a  pillow  for  a  year,  as  she 
could  not  hold  her  head  up.  Patient  began  to  walk  at  3|  years,  and  became  very  active.  At  5  years,  a  few 
words,  such  as  "  ma,"  "  pa,"  "  money,"  "  goodbye,"  "  bad  boy,"  were  said.  The  patient  is  described  as 
having  tried  very  hard  to  say  more  words  but  as  being  unable  to  shape  them.  When  desiring  to  attract 
attention  to  something,  she  would  say  "Bookit."  At  the  age  of  5,  she  had  learned  to  use  a  spoon  and 
fork,  and  kept  her  person  clean.  She  was  restless  in  sleep.  There  was  a  history  of  middle  ear  disease  on 
both  sides  in  early  childhood.     Patient  was  a  mouth-breather,  with  large  tonsils. 

4  and  6.  School  Progress  and  Examinations.—  Patient  upon  admission  was  unable  to  take  the 
regular  school  work  and  was  placed  in  the  training  classes;   although  kept  in  these  classes  for  several 


90  SOUTHARD  AND  TAFT. 

years,  she  made  very  little  advance.     She  learned  to  march  in  step  and  could  play  very  simple  games. 
She  could  not  be  taught  to  match  color  and  form. 

6.  Practical  Knowledge.— When  admitted  to  the  school,  the  patient  was  untidy,  but  became 
thoroughly  tidy  after  training.  She  was  able  to  feed  herself,  and  to  dress  and  undress  herself,  although 
careless  with  the  clothing  and  inclined  to  be  destructive  thereof.  Patient  learned  to  do  simple  work 
with  the  hands,  such  as  cutting  paper  and  cloth,  but  could  not  cut  to  a  line. 

7.  Economic  Efficiency.—  Nil.  Patient  was  able  to  do  simple  domestic  work,  such  as  dusting 
and  rubbing  the  floor,  and  could  make  a  bed  with  help. 

8.  Social  History  and  Reactions. — ■  Patient  would  often  walk  towards  a  person  as  if  about  to 
speak,  and  then  draw  back,  repeating  this  action  several  times  in  succession.  When  excited,  patient 
would  jump  up  and  down  and  scream,  whether  pleased  or  displeased,  and  would  laugh  and  cry  at  the 
same  time. 

9.  Moral  Reactions. —  Patient  is  described  as  having  been  of  a  good  temper  during  her  Waverley 
School  life.  She  was  fond  of  music  and  liked  to  look  at  picturebooks.  Was  apparently  perfectly  happy 
if  given  a  doll  or  other  toy.  She  was  particular  about  food,  liking  goodies.  She  was  always  rather 
excitable  and  noisy,  and  interpretation  of  her  emotion  was  difficult  on  account  of  the  identity  of  reactions 
when  pleased  or  displeased.  Patient  gave  the  impression  of  laughing  and  crying  at  the  same  time. 
Patient  masturbated. 

10.  Psychological  Tests. —  Patient's  mental  age  was  5  years. 

Waverley  School  History. —  Patient  was  admitted  to  the  school,  June  20, 1895,  and  after  remaining 
a  few  months,  was  taken  home  by  her  mother.  She  was  re-admitted  in  1896,  at  the  age  of  8  years.  She 
was  very  seldom  sick  at  the  school,  dragged  her  feet,  and  stood  and  sat  in  a  roundshouldered  attitude. 
She  would  march  in  step  if  some  one  put  hands  on  her  shoulders  in  the  proper  way.  Patient  is 
described  as  running  about  in  a  lackadaisical  manner,  and  as  having  a  habit  of  skipping  with  one  foot. 
She  played  relay  races  well,  but  was  unable  to  see  the  point  of  some  of  the  simple  circle  games.  Patient 
was  addicted  to  talking,  and  was  more  or  less  troublesome.  She  showed  a  number  of  peculiar  move- 
ments; for  example,  she  would  roll  and  pick  the  front  of  her  dress  with  her  hands,  and  finish  the  process 
by  holding  a  bunch  of  clothing  in  her  left  hand,  passing  her  right  hand  in  circles  over  her  head.  Another 
characteristic  action  was  pointing  her  finger  downward  with  arm  extended,  and  repetition  of  "  Yah, 
mamma,  yah."  Now  and  then  she  would  shake  her  head  and  squint  her  eyes.  Toward  the  close  of 
life  she  had  lost  much  weight  and  apparently  also  in  height.  Tuberculosis  was  made  out  in  March, 
1914,  just  before  her  death,  involving  the  entire  left  lung  and  right  apex. 

b)    Autopsy. 

Autopsy. —  Head,  trunk  and  cord,  Dr.  M.  M.  Canavan. 

Body. —  That  of  a  somewhat  emaciated,  slender  white  female,  146  cm.  in  length.  Skin  waxy  yellow 
white  in  color.  There  is  an  abrasion  over  the  right  cheek,  punctate  in  character,  2  cm.  in  diameter.  No 
decubitus  scars,  edema,  nor  palpable  lymph  nodes.  Axillary  hair  absent,  pubic  hair,  yellow,  grows  in  an 
eliptoid  manner  4  cm.  above  the  symphysis,  and  cylindrically  over  the  labia  majora.  Left  nipple  appears 
rudimentary.     3d  and  4th  toes  on  both  feet  much  shorter  than  1st  or  2nd. 

Abdomen  distended  and  gives  hollow  note  on  percussion. 

Pupils  equal,  0.3  cm.  Nose  deflected  slightly  to  left.  Upper  teeth  slightly  uneven,  (suggestion  of 
early  nutrition  disease)  ridged,  but  no  trace  of  uneven  cutting  edge.  Orbital  arches  flattened,  forehead 
measures  8  cm.  in  height  above  them  and  is  a  straight,  not  a  curved  line. 

Ventral  section. —  Panniculus  nil.  Muscles  in  remarkable  rigor.  Peritoneum  shining  and  grey. 
Stomach  20  cm.,  Liver  11  cm.  below  ensiform.  Spleen  large  and  free  from  adhesions.  Appendix  5.5  cm. 
in  length,  somewhat  injected,  has  a  mesentery  of  its  own.     Mesenteric  lymph  nodes  not  enlarged.     Ad- 


WAVERLEY   RESEARCHES.    II.  91 

hesions  exist  between  lower  inferior  edge  of  liver  and  the  transverse  and  ascending  colon.    Some  free 
fluid  —  estimated  150  cc.  thin  and  pale  in  color  exists  in  peritoneal  cavity. 

Pelvis. —  The  uterus,  5  cm.  in  length,  is  in  an  anterior  position;  the  right  ovary  measures  5  X  2.5  X 
1.0  cm.;  the  left  ovary  measures  3  X  1.5  X  1.0  cm. 

Diaphragm. —  Reaches  to  the  5th  interspace  on  right,  to  the  6th  rib  on  left.  Ribs  are  remarkably 
close  together  —  hardly  an  intercostal  space  that  was  more  than  0.5  cm.  in  width. 

Thorax. —  Lungs  adhere  to  chest  wall  closely  showing  on  the  right  a  yellow  puriform  open  space, 
and  the  left  is  evenly  consolidated  on  palpation  with  recent  fibrin  at  apex.  Lungs  not  removed  but  cut 
in  situ  with  the  cavitation  of  right  apex  seen:  it  is  extensive. 

Heart. —  Assumes  circular  form  —  epicardial  fat  scant  —  coronaries  small  —  not  sclerosed.  Myo- 
cardium grey  white.     Endocardium  not  notable. 

Valve  measurements:    TV,     10.0  cm.     P  V,  6.0  cm.     LV,  1.0  cm. 
MV,      9.0  "       AV,  5.0  ■       RV,  0.5  ■ 

The  aortic  valve  is  miniature  in  size  of  leaflets,  and  there  is  some  sclerosis  of  the  origins  of  the  coro- 
naries.    The  arch  of  the  aorta  is  smooth  —  diameter  of  arch  2.0  cm. 

Organs  of  neck. —  Not  removed. 

Abdomen:  Spleen. —  13  X  9  X  3  cm.  Markedly  large;  trabeculae  distinct  —  pulp  slightly  watery 
and  pale.     No  Malpighian  bodies. 

Adrenals. —  None  seen. 

Kidneys. —  Right  much  smaller  than  left;  contains  only  three  pyramids.  Capsule  thick,  cortex  pale 
and  does  not  show  injection.     Pelvis  very  large  —  somewhat  injected. 

Liver. —  Somewhat  large.  Capsule  of  Glisson  is  thickened,  inferior  edges  fairly  blunt.  Color  red- 
brown.     Nothing  of  note  on  section.     Gall-bladder  wall  white  and  edematous.     No  stones. 

Pancreas. —  Not  examined. 

G astro-intestinal  tract. —  Stomach  large  and  distended.  Rugae  not  present.  Intestines  negative 
throughout. 

Genito-urinary  tract. —  Ovaries  contain  pigmented  scars  —  (has  not  menstruated  for  a  year). 

Retroperitoneal  tissues. —  Peripheral  nerves  negative.  Sympathetic  chain  seems  vastly  broken  up 
into  fine  threads. 

Head. —  Hair  fine  and  abundant  if  short.  Scalp  pale,  scanty  in  fat.  Temporal  muscles  fairly  well 
developed.  Calvarium  0.3  cm.  frontal,  0.1-0.3  cm.  temporal,  0.4  cm.  occipital;  it  is  very  dense  and 
eburnated;  no  diploe.  At  the  junction  of  the  coronal  and  sagittal  sutures  the  dura  is  markedly  adherent 
(the  brain  herniating  through  small  points  of  cut  dura  on  forcible  removal)  and  the  dura  is  thickened 
from  this  central  point  to  the  area  of  middle  meningeal  distribution.  Vertex  is  ball  shaped  and  small. 
Pia  mater  is  thin  and  delicate  except  over  sulci  and  vertex  where  faint  hazing  appears. 

Hemispheres  equal  but  appear  very  shortened  in  the  frontal  portion  as  though  the  whole  prefrontal 
area  were  missing.  Convolutions  are  simple  and  shallow,  running  with  no  complexity  to  the  longitudinal 
sinus.  Post  rolandic  gyri  simple  in  pattern.  No  inequalities  on  palpation.  At  the  base  the  temporal 
lobes  are  exceedingly  plump,  and  make  the  distance  between  their  free  edges  and  the  frontal  pole  appear 
very  short. 

Basal  arteries  clear. 

Optic  and  3d  nerves  negative. 

Gasserian  ganglions  negative. 

Pituitary  softened.     Middle  ears  —  left  drum  ruptured,  right  not  seen. 

Cerebellum,  pons  and  cord  negative. 

Brain  weight,  1270  gms. 


92 


SOUTHARD   AND  TAFT. 


Anatomical  Diagnosis. 


Emaciation.  Pulmonary  tuberculosis,   (advanced). 

Abrasion  of  right  cheek.  Cloudy  swelling  of  heart  muscles. 

Absence  of  axillary  hair.  Right  heart  hypertrophy. 

Anomaly  pubic  hair.  Aortic  stenosis. 

Rudimentary  left  nipple.  Anomalous  kidney. 

Anomaly  of  toes.  Chronic  perihepatitis. 

Distention  of  abdomen.  Chronic  cholecystitis. 

Nose  deflected  to  left.  Anomalous  sympathetic  ganglionated  cord. 

Malnutrition  ridges  on  teeth.  Calvarium  dense. 

Forehead  high  and  flat.  Chronic  external  adhesive  pachymeningitis 

Splanchnoptosis.  (focal). 

Slight  injection  of  appendix.  Chronic  fibrous  pachymeningitis  —  (middle 

Chronic  peri-colitis.  meningeal). 

Slight  ascites.  Slight    chronic    leptomeningitis    sulcal    and 

Ovaries  very  large.  vertex. 

Ribs  closely  set.  Anomalous  frontal  poles  (shortening). 

Chronic  adhesive  pleuritis.  Simplicity  of  convolutions. 

c)     Special  Anatomical  Description  of  Brain. 

A  more  detailed  description  of  the  brain  is  as  follows :  —  The  brain  is  of  fair  size  and  suits  the  dolicho- 
cephalic type  of  skull.  The  dura  mater  was  attached  rather  more  firmly  than  usual  to  the  pia  mater 
and  the  brain  by  means  of  numerous  pial  vessels  and  their  investments.  There  is  no  evidence  of  arterio- 
sclerosis. The  pia  mater  is  everywhere  slightly  thickened  and  of  a  dull,  cloudy  appearance. 
[^  There  is  slight  asymmetry  of  the  two  hemispheres;  the  right  is  shorter  than  the  left,  and  the  right 
occipital  lobe  points  away  from  the  median  line.  The  convolutions  are  everywhere  of  fair  width  and 
usually  well  rounded  and  approximated. 

In  the  frontal  lobe,  the  dividing  sulci  are  distinct.  On  both  sides  the  first  sulcus  cuts  across  the 
precentral  gyrus.     The  second  frontal  gyrus  is  broader  than  the  first  on  both  sides. 

The  central  convolutions  are  quite  narrow,  the  postcentral  notably  so. 

The  pattern  of  the  parietal  lobes  is  in  general  transverse  in  direction;  the  interparietal  sulci  are 
interrupted  by  an  annectant  between  the  postcentral  gyrus  and  the  superior  parietal  lobule  on  both 
sides.  This  leaves  the  ascending  postcentral  sulcus  separate  from  the  descending  portion  and  the 
horizontal  branch.  On  the  right,  at  the  junction  of  the  descending  and  horizontal  interparietal  sulci, 
there  is  a  distinct  rosette  formation.  The  size  of  the  two  parietal  lobules,  superior  and  inferior,  is  nearly 
the  same  on  both  sides. 

The  occipital  surfaces  are  not  notable  except  for  the  slight  asymmetry  already  remarked  upon. 

On  the  base  of  the  brain  the  orbital  surface  presents  the  usual  triradiate  sulcal  pattern. 

The  collateral  fissure  on  both  sides  is  continuous  with  the  fissura  rhinica  (Turner),  thus  separating 
the  pyriform  lobule  entirely  from  the  temporal  lobe.  The  right  pyriform  lobule  appears  somewhat  larger 
on  the  right  than  on  the  left. 

The  mesial  surfaces  present  no  remarkably  anomalous  cortical  pattern.  The  corpus  callosum  is  nar- 
row in  its  horizontal  portion  as  compared  with  the  rostrum  and  splenium.    There  is  no  middle  commissure. 

The  frontal  sections  show  no  pathological  lesions.  The  cortex  is  everywhere  of  good  width.  There 
appears  to  be  a  rather  smaller  corona  radiata  than  one  usually  finds.  The  basal  gray  matter  is  present 
in  the  usual  amount. 


WAVERLEY   RESEARCHES.    II. 


93 


The  callosal  angles  of  the  lateral  ventricles  are  rounded,  but  there  is  no  definite  enlargement  of  the 
ventricle  cavity. 

The  cerebellum,  pons  and  medulla  are  negative  to  gross  examination. 

d)  Microscopic  Examination. 

The  results  of  partial  microscopic  examination  may  be  stated  as  follows : — 

The  most  striking  and  general  characteristic  of  the  tissues  is  the  generalized  gliosis  involving  both 
anjincrease  of  cells  and  increase  of  fibrils.  This  gliosis  affects  the  spinal  cord  as  well  as  encephalic  tissues. 
There  is  a  suggestion  of  narrowing  of  the  cortex  cerebri  throughout  and  a  crowding  together  of  the  lami- 
nae. The  blood  vessels  are  everywhere  prominent;  this  appearance  is  partly  due  to  thickening  but 
largely  due  to  the  frequency  of  perivascular  gliosis. 

One  of  the  most  important  findings  in  the  case  is  that  of  rod  cells  such  as  were  found  in  case  VI 
(although  in  case  VI  there  are  a  few  foci  of  perivascular  infiltrations).  The  variations  in  the  different 
areas  examined  are  quantitative  rather  than  qualitative.  The  rod  cells  are  found  most  frequently  in  the 
precentral,  post  central,  calcarine  and  temporal  areas. 

One  area,  the  right  transverse  temporal,  shows  a  canalized  thrombus  in  a  small  vessel,  with  a 
vacuole  or  approach  to  a  small  glia-lined  cyst  nearby.  There  is  a  small  acute  hemorrhage  under  the  pia 
mater  of  the  right  angular  gyrus.  The  right  superior  frontal  region  appears  to  show  a  larger  degree  of 
cell  atrophy  (with  numerous  shadow  cells)  than  is  found  elsewhere. 

e)    Anatomical  and  Histological  Summary. 

This  brain  of  an  imbecile  weighed  1270  grams,  is  fairly  complex  in  construction,  of  fair  size,  with 
slight  asymmetry  and  a  narrow  corpus  callosum  as  to  its  horizontal  part.  There  is  apparently  no  definite 
enlargement  of  the  ventricular  cavity.  Microscopically  there  is  a  generalized  gliosis  which  involves  not 
only  the  encephalic  tissues  but  the  spinal  cord.  The  most  important  finding  in  the  case  is  that  of  rod 
cells,  as  in  Case  VI,  but  the  perivascular  infiltrations  of  Case  VI  are  not  present  in  Case  VII.  The  rod 
cells  are  more  widely  distributed  in  the  present  case. 

A  canalized  thrombus  in  one  region  may  be  regarded  as  another  sign  of  acquired  lesion;  but  as  to 
the  date  of  this  lesion  nothing  can  be  said.  Note  is  made  below  of  the  fact  that  the  mental  age  of.  this 
patient,  set  in  a  general  way  at  5  years,  was  regarded  in  some  respects  as  over-estimated  since  in  a  number 
of  directions  the  patient  appeared  to  verge  upon  idiocy. 


Synopsis  of  Findings  or  Case  VIII. 
a)  Clinical. 

This  case  will  probably  be  reported  in  extenso  elsewhere  in  collaboration  with  Dr.  G.  B.  Magrath, 
Medical  Examiner  of  Suffolk  County,  who  performed  the  autopsy  in  pursuance  of  official  duty.  We 
have  acted  as  his  deputies  in  executing  our  brain  studies. 

The  case  belongs  in  Dr.  Magrath's  series  of  "judicial  homicides"  having  been  electrocuted  for 
murder.  A  number  of  more  or  less  competent  persons  regarded  the  subject  as  "defective."  Further 
details  are  reserved  for  the  present.  The  brain  is  presented  as  a  foil  to  the  others  of  the  series.  If 
"feeble-mindedness"  is  a  term  roughly  equivalent  to  inability  of  self-support,  then  this  subject  should 
perhaps  not  be  regarded  as  feeble-minded.  If  "defect"  may  be  used  to  include  lack  of  "normal  inhibi- 
tion," then  probably  this  case  might  classify  as  defective. 

The  subject  was  physically  well  developed,  had  been  a  "nervous"  and  "bad"  boy,  could  read  and 
write,  had  marked  practical  ability  in  certain  ways,  earned  a  sort  of  living,  was  criminalistic,  had  an 


94  SOUTHARD  AND  TAFT. 

ungovernable  temper  and  was  easily  overcome  by  alcohol.     There  is  no  means  of  knowing  what  his 
mental  "grade"  would  have  been;  we  have  placed  it  at  12  plus. 

b)  Autopsy. 
Gross  findings  reserved. 

c)     Special  Anatomical  Description  of  Brain. 

There  is  slight  asymmetry  of  the  occipital  lobes ;  the  right  is  thin  and  points  away  from  the  median 
line,  while  the  left  does  not. 

The  pia  is  thickened  and  white  over  the  vertex,  and  the  vessels  are  considerably  injected;  particu- 
larly the  larger  ones. 

The  convolutional  pattern  is  noticeable  in  that  the  direction  of  the  gyri  is  a  transverse  rather  than 
an  antero-posterior  one.  (This  has  been  noted  as  a  developmental  anomaly  in  mental  defectives.)  The 
gyri  are  well  rounded  and  of  fair  width,  but  their  summits  are  not  approximated.  The  markings  are  of 
medium  complexity  in  the  anterior  region,  but  less  so  in  the  part  adjacent  to  the  central  lobule. 

In  the  central  region  the  precentral  gyrus  is  unusually  wide  in  its  upper  third;  the  postcentral  is 
very  narrow  in  its  upper  third,  but  becomes  of  average  width  below.  The  upper  extremity  of  the  fissure 
of  Rolando  extends  barely  to  the  border  of  the  superior  longitudinal  fissure  and  approaches  it  at  an  acute 
angle.     The  lower  extremity  does  not  cut  the  operculum. 

The  parietal  lobes  are  well  developed  with  distinct  markings.  On  the  right  the  interparietal  sulcus 
is  typical;  the  postcentral  portion  is  continuous  and  is  intercepted  at  its  middle  point  by  the  horizontal 
limb.  On  the  left  the  ascending  postcentral  is  separated  by  a  narrow  annectant  from  the  descending 
and  horizontal  branches,  which  are  continuous.  The  convolutions  of  the  inferior  parietal  lobule  are 
broader  and  less  complex  than  those  of  the  superior  parietal.  This  lobule  is  marked  both  by  longitudinal 
and  transverse  fissures.  The  entire  lobe  is  characterized  by  the  lack  of  approximation  of  the  walls  of  the 
interparietal  fissure  and  of  the  convolutions  of  the  superior  lobule. 

The  occipital  lobe  is  not  remarkable;  the  convolutions  are  of  good  width,  fairly  well  rounded,  their 
walls  well  approximated,  and  of  complex  arrangement. 

On  the  orbital  surface  the  convolutional  pattern  is  not  markedly  different  from  that  ordinarily  seen. 

The  pyriform  lobules  are  noticeably  asymmetrical;  the  right  is  considerably  wider  than  the  left, 
and  this  is  true  of  the  entire  hippocampal  lobule.  The  rhinal  fissure  (Turner)  is  well  marked.  The 
convolutions  of  the  extreme  tip  of  the  right  occipital  lobe  are  narrow  and  irregularly  arranged.  The 
sulcal  pattern  over  the  entire  base  of  the  brain  is  unusually  symmetrical. 

The  main  differences  of  configuration  on  the  mesial  surface  are  the  presence  on  the  left  of  two  sulci 
parallel  with  the  callosum,  while  on  the  right  there  is  but  one.  On  the  left,  the  parietooccipital  fissure 
is  wide  open,  disclosing  an  otherwise  hidden  convolution  which  dips  down  from  the  superior  surface  of 
the  superior  parietal  lobule  and  turning  back  upon  itself,  joins  posteriorly  with  the  superior  occipital 
gyrus.  The  sulcal  complex  on  the  right  precuneus  is  triradiate,  while  that  on  the  left  is  made  up  of  four 
branches.  The  former  has  one  fissure  extending  upward  toward  the  superior  margin,  and  two  downward 
and  outward;  on  the  left  two  point  upward  and  outward,  and  two  downward  and  outward. 

The  callosum  is  of  good  extent  and  thickness  except  in  the  posterior  third  of  the  horizontal  portion 
where  there  is  moderate  narrowing.    The  middle  commissure  is  present. 

The  frontal  sections  illustrate  well  the  lack  of  complete  longitudinal  sulci  in  the  frontal  lobes;  these 
can  be  easily  identified  only  in  the  most  anterior  portion. 

There  is  nothing  remarkable  in  the  appearance  of  the  cortex,  nor  of  the  basal  nuclei. 

The  ventricles  are  not  dilated. 


WAVERLEY   RESEARCHES.    II. 


d)    Microscopic  Examination. 


95 


The  results  of  a  partial  microscopic  examination  may  be  abstracted  as  follows :  — 

Gliosis  is  noted  in  numerous  areas  but  was  rarely  of  marked  degree  and  often  showed  a  tendency  to 
focalization.  Subpial  gliosis  is  noted  in  the  paracentral,  postcentral  (more  marked  left),  temporal 
pyriform,  cornu  ammonis,  left  prefrontal,  right  insula,  and  Broca  areas.  This  subpial  gliosis  is,  as  a  rule, 
more  marked  at  the  bottoms  of  the  sulci  or  along  their  sides  than  at  the  tops  of  the  gyri.  It  is  not  often 
of  marked  degree. 

Perivascular  gliosis  is  especially  noted  in  the  right  precentral,  right  middle  temporal,  superior  frontal, 
middle  frontal  prefrontal  and  Broca  areas. 

Satellitosis  is  especially  noted  in  the  paracentral,  right  postcentral,  left  cornu  ammonis,  superior 
frontal,  middle  frontal,  prefrontal  and  insula  regions,  and  to  a  lesser  extent  in  several  other  regions. 
Gliosis  of  the  white  matter  is  especially  noted  in  the  right  middle  temporal,  middle  frontal,  prefrontal, 
insula  and  Broca  areas,  as  well  as  in  areas  noted  above,  showing  perivascular  gliosis  in  the  white  matter. 

Dislocated  ganglion  cells  are  noted  especially  in  the  white  matter  of  the  right  precentral  area  and 
appear  in  general  to  be  rare  in  this  case. 

The  only  instance  of  exudate  consists  in  infiltration  of  the  space  about  the  small  blood  vessels  in  the 
left  prefrontal  region,  where  cells  are  found  highly  suggestive  of  plasma  cells.  Evidence  of  recent  cell 
destruction,  completed  or  in  process,  are  few  but  distinct.  The  notes  show  cells  with  poorly  staining 
nuclei  and  surrounded  at  their  bases  by  satellite  cells  in  both  paracentral  regions.  Satellitosis  was  also 
found  in  the  postcentral  region  in  considerable  degree. 

In  the  right  transverse  temporal  gyrus,  cells  are  occasionally  found  of  the  small  pyramidal  type, 
having  a  clear  ring  outside  the  nucleus,  suggesting  that  the  chromatic  substance  had  undergone  a  solvent 
process  in  the  cell  interior.  Shadow  cells  are  found  in  the  pyriform  lobules  and  are  here  associated  with 
cells  showing  the  clear  perinuclear  rings  just  mentioned  as  found  in  the  transverse  temporal  region. 
Other  areas  show  occasional  cell  changes  of  the  same  general  nature. 

The  total  brain  sections  in  this  case  show  deep  sulci,  possibly  more  so  on  the  left  side;  the  cortex 
roughly  averages  3  mm.  in  depth  at  the  summits  of  the  gyri  and  is  thinner  elsewhere.  The  white  matter 
appears  to  preserve  a  fair  proportion  to  the  cortex.  There  seems  to  be  notably  less  white  matter  on  the 
left  side  of  the  brain.  The  larger  vessels  in  the  white  matter  are  surrounded  by  large  pigment-laden 
cells. 

Especially  interesting  was  a  slight  degree  of  heterotopia  of  the  gray  matter  consisting  in  four  small 
areas  below  the  cortex  on  the  superior  surface  of  the  temporal  lobe.  The  blood  vessels  of  the  temporal 
lobe  show  dilatation  of  their  perivascular  spaces  with  a  few  large  pigmented  cells.  The  ventricles  are 
not  dilated;  the  corpus  callosum  is  of  proper  thickness,  approximately  8  mm. 

It  does  not  appear  that  there  is  any  evidence  of  thinning  out  of  the  nerve  fibers.  The  suggestion 
that  the  left  hemisphere  has  comparatively  less  white  matter  than  the  right  is  based  upon  observations 
both  in  the  anterior  and  posterior  part  of  the  brain. 

e)    Anatomical  and  Histological  Summary. 

This  brain  (1340  grams)  in  a  physically  healthy,  executed  subject,  is  found  to  show  a  number  of 
minor  asymmetries,  such  as  the  transverse  direction  of  convolutional  pattern  in  many  regions.  The 
summits  of  the  gyri  are  not  always  approximated.  The  corpus  callosum  is  of  proper  size  except  for  a 
moderate  narrowing  in  the  posterior  third  of  the  horizontal  portion,  in  which  latter  connection  may  be 
mentioned  that  the  parietal  lobules  are  especially  characterized  by  the  lack  of  approximation  of  the  walls 
of  the  gyri. 


96  SOUTHARD  AND  TAFT. 

Microscopically  there  is  a  certain  tendency  to  slight  gliosis  of  a  focalized  nature.  This  gliosis  is  more, 
as  a  rule,  at  the  bottoms  of  the  sulci  where  there  is  normally  more  fiber-producing  tissue.  Both  the 
fibrillar  gliosis  and  satellitosis  are  fairly  widespread  in  cortex  and  white  matter  and  there  is  a  certain 
amount  of  perivascular  gliosis.  The  argument  for  fundamental  hypoplastic  changes  may  perhaps  best 
be  based  upon  dislocated  ganglion  cells  in  the  white  matter  of  the  right  precentral  area,  but  the  rarity 
of  such  cells  is  conspicuous  and  it  would  not  seem  well  to  make  a  diagnosis  of  hypoplasia  or  heterotopia 
upon  this  single  finding.  Again,  the  single  focus  of  perivascular  infiltration  by  cells  resembling  plasma 
cells  in  the  left  prefrontal  region  is  perhaps  but  slight  evidence  on  which  to  ground  the  hypothesis  of  brain 
changes  of  an  important  nature  in  this  executed  criminal.  A  vast  deal  of  comparative  work  in  "  normal" 
cases  must  yet  be  done  before  a  decision  can  be  rendered  on  such  a  point. 

That  the  case  had  inborn  peculiarities  may  be  argued  from  the  stigma  of  heterotopia  in  the  temporal 
lobe  and  perhaps  somewhat  upon  the  deep  sulci,  possibly  deeper  on  the  left  side,  which  the  total  brain 
section  demonstrated.  The  suggestion  that  there  is  somewhat  less  white  matter  on  the  left  side  of  the 
brain  than  on  the  right  may  also  be  entertained  as  indicative  of  inborn  peculiarity.  There  is  in  the  case 
apparently  no  evidence  of  thinning  out  of  the  nerve  fibers. 

An  analysis  of  this  case  in  comparison  with  others  in  a  series  of  executed  homicides  will  be  profitable. 


Synopsis  of  Findings  of  Case  IX. 
a)     Clinical. 

1.  Physical  Examination. —  Patient  was  born  August  3,  1875;   admitted  May  17,  1883;    died 
•  August  30,  1914.     The  patient  at  autopsy  showed  an  enlarged  thyroid  and  cystic  kidneys,  but  had  no 

other  anomalies.    The  stomach  was  dilated.     He  is  described  as  having  been  a  strong  and  healthy 
subject. 

Voice  hoarse,  words  pronounced  in  a  staccato  manner.  Patient  a  little  deaf;  at  all  events,  later  in 
life. 

2.  Family  History. —  Father  and  mother  are  said  to  have  been  strong  and  healthy;  the  father  30, 
and  the  mother  32  years  old  at  the  time  of  the  birth  of  this  child.  There  had  been  four  children  before 
the  birth  of  the  patient,  and  one  thereafter.  One  of  the  children  had  died  of  "  summer  complaint."  It 
is  stated  that  there  are  no  evidences  of  deformity  or  mental  deficiency  in  the  other  children.  The  mother 
died  in  childbirth,  at  37  years.     The  family  was  American. 

3.  Personal  Developmental  History. —  Patient  began  to  walk  at  2  years,  and  to  say  a  few  words 
at  5  years.  His  mental  deficiency  was  noticed  at  3  years  of  age,  when  it  appeared  that  he  was  not  trying 
to  talk.  At  8  years,  when  patient  was  admitted  to  the  school  at  South  Boston,  he  could  not  talk  plainly 
and  had  untidy  habits.     He  had  not  learned  to  read  or  write. 

4  and  5.  School  Progress  and  Examinations. —  Patient  upon  admission  was  placed  in  the  train- 
ing classes,  and  learned  a  good  deal.  He  learned  to  do  simple  outdoor  work  on  the  farm,  such  as  grub- 
hoeing,  picking  up  stones,  and  the  like.  In  his  25th  year,  he  was  transferred  to  the  Colony,  where  he 
developed  markedly  and  was  regarded  as  fairly  intelligent  and  industrious.  His  strength  and  abundance 
of  health  permitted  him  to  help  the  blacksmith;  he  could  measure  and  saw  off  wood,  and  use  a  plane 
and  sandpaper.     He  would  keep  the  blacksmith's  tools  lined  up  for  him,  and  assist  in  shoeing  oxen. 

6.  Practical  Knowledge. — -His  practical  knowledge  is  indicated  by  the  remarks  under  School 
Progress  (see  above).  Although  he  could  use  the  plane,  saw,  and  chisel  well,  his  sense  of  measurement 
was  so  deficient  that,  for  instance,  he  could  not  tell  the  difference  between  5  and  9  inches.  However, 
if  given  a  piece  of  board  4  inches  wide,  patient  could  go  and  get  another  of  the  same  width.     If  the  car- 


WAVERLEY   RESEARCHES.    II.  97 

penter  marked  with  pencil  a  line  to  which  patient  was  to  plane  on  a  piece  of  board,  he  could  plane  to  that 
mark.     Practically  speaking,  he  seemed  to  be  better  than  his  Binet  age  would  indicate. 

7.  Economic  Efficiency.—  See  above. 

8.  Social  History  and  Reactions. —  Patient  was  much  beloved  by  the  caretakers.  He  was  kind- 
hearted  and  anxious  to  please,  and  after  his  fashion  had  a  very  keen  sense  of  humor,  apparently  under- 
standing much  more  than  he  was  able  to  express;  used  nouns,  active  verbs,  and  a  few  descriptive  words, 
but  never  learning  to  put  sentences  together. 

9.  Moral  Reactions. —  Patient  belonged  in  the  amiable  and  "  altruistic  "  group. 

10.  Psychological  Tests. —  Binet  tests  performed  in  1914  show  the  patient  to  be  of  a  mental  age 
of  7. 

W  averley  School  History. —  The  advance  of  this  patient  under  supervision  and  the  conditions  of 
the  school,  and  later  of  the  colony,  was  considerable,  as  above  indicated.  As  the  patient  grew  older, 
he  was  given  more  difficult  wrork,  which  he  was  able  to  perform  with  fair  satisfaction ;  this  progress  was 
of  a  degree  rather  unusual  in  the  feeble-minded.  Patient  was  fond  of  music  and  of  humming  melodies, 
although  he  did  not  pronounce  the  words. 

The  patient  was  killed  by  being  run  down  by  an  automobile  while  being  taken  off  the  grounds  with 
a  group  of  boys  on  an  outing.  He  had  been  in  general  regarded  as  able  to  take  care  of  himself  and  keep 
out  of  the  way  of  traffic,  although  the  conditions  of  state  roads  may  have  been  more  complex  than  ordi- 
nary for  him.     There  was  a  certain  error  of  judgment  on  the  part  of  the  automobile  driver. 

b)     Autopsy. 

Body  of  a  well  built  and  nourished  white  male  5  ft.,  10  in.  in  length  (177.8  cm.).  Skin  rosy  grey 
but  shows  marked  number  of  recent  abrasions  as  follow: 

Right  parietal  boss  is  prominent  and  exhibits  a  superficial  cut  5  cm.  in  length  by  0.5  cm.  in  width. 
Hair  shaved  on  this  side.  Right  mid  scapular  line  shows  abrasions  3  X  0.5  cm.  Right  elbow  3  small 
ones  3X2  cm.  in  extent.  Right  lumbar  region  just  above  crest  of  ilium  5.0  cm.  X  1  cm.  Right  popliteal 
space  5X1  cm.  Right  knee  inner  aspect  3  X  0.8  cm.  Right  mid  shin  anterior  aspect  3X2  cm.  Left, 
below  crest  of  ilium  (gleutial  side)  an  abrasion  12  cm.  in  length  X  2  cm.  wide.  Left  thigh  lower  third 
outer  aspect  is  another  3X1  cm.  Left  knee  inner  aspect  2X2  cm.  Bruises,  right  knee,  right  shin, 
right  ankle  (inner  and  outer  aspects),  left  ankle  slight  bruising  7X7  cm. 

Rigor  mortis  present,  in  legs  —  not  in  arms.  No  palpable  lymph  nodes.  Pupils  0.5  cm.  equal. 
Slight  amount  regurgitated  material  left  face  and  neck. 

Ventral  Section. —  Fat  over  abdomen  measures  3j  cm.  Over  thorax  5  cm.  Muscles  red.  Peri- 
toneum is  bluish  red  in  lower  anterior  portion  and  there  is  blood  between  the  fascia  of  the  rectii  muscles 
and  the  peritoneum  as  high  as  10  cm.  above  the  symphysis.  There  is  free  blood  in  the  peritoneal  cavity, 
estimated  quantity  25-40  cc.  The  intestines  are  dilated,  the  liver  is  above  costal  margin  and  lightly 
stained  with  blood.  Stomach  dilated  and  10  cm.  in  length.  Spleen  free.  Mesenteric  lymph  nodes  not 
palpable.  Hemorrhages  exist  in  the  layers  of  the  mesentery.  Diaphragm  arches  to  the  4th  rib  in  right 
to  4th  on  left. 

Thorax. —  Muscles  removed  from  anterior  thoracic  wall  shows  much  hemorrhage  into  the  muscles 
between  the  left  clavicle  and  sternum  between  1st  and  2nd  rib.  On  the  right  between  clavicle  and 
first  and  between  1st  and  2nd  ribs,  there  is  a  separation  of  the  clavicle  and  the  sternum  on  the  left 
by  hemorrhagic  and  edematous  muscle  and  the  first  rib  is  broken  approximately  1  cm.  from  the  junc- 
tion of  it  to  sternum.  On  the  right  the  upper  end  of  the  chest  wall  sinks  in  a  little  more  than  the 
left  and  a  fracture  is  present  on  right  first  rib  8  cm.  from  mid  sternal  line  and  the  2nd  is  also 
fractured  somewhat  latterly  to  the  first.  Anterior  portion  right  chest  presents  subperiosteal  fractures 
of  the  7th,  8th,  9th  and  10th  ribs  with  marked  hemorrhage  into  parietal  pleura.    None  on  the  left. 


98  SOUTHARD   AND  TAFT. 

Upon  removal  of  the  lungs,  there  is  also  seen  marked  hemorrhage  in  posterior  surface  of  right  pleura  and 
underneath  it  the  3rd,  4th,  5th,  6th,  7th,  8th  ribs  are  fractured  about  1-3  cm.  from  vertebrae  and  10  cm. 
from  vertebrae  the  10th  and  11th  ribs  are  also.  Marked  hemorrhage  into  posterior  mediastinal  tissue, 
on  either  side,  also  retroperitoneally  in  abdomen.  Heart  weight  12J  oz.  (354  grams).  Epicardial  fat 
scant,  muscle  somewhat  pale  but  firm.     Valves  negative.     Endocardium  smooth. 

Measurements:   T.V.  5|  in.  (14cm.)       P.V.  3j  in.  (8.25cm.)     L.V.  Jin.  (1.2cm.). 
M.V.  4f  in.  (12.0  cm.)     A.V.  3|  in.  (8.8  cm.)      R.V.  §  in.  (0.3  cm.). 

Lungs. —  Right  22J  oz.  (638  grams).  Left  20J  oz.  (567  grams.).  Nothing  of  note  except  old  adhe- 
sions left  apex  and  recent  congestion  of  both  lungs. 

Organs  of  the  Neck. —  Thyroid  markedly  enlarged  and  protuberant;  weighs  3j  oz.  (99  gms.).  Normal 
on  section  except  right  lobe  which  is  very  much  congested.     Tongue,  larynx,  trachea,  esophagus  negative. 

Abdomen. —  Spleen  6j  oz.  (184  gms.).  Nothing  of  note.  Capsule  not  thick,  pulp  fairly  soft,  trabe- 
culae  prominent.     Adrenals  small;   otherwise  negative. 

Kidneys  9|  oz.  (269  gms.).  One  kidney  fairly  normal;  the  other,  the  left,  is  studded  with  smooth, 
firm  glistening  bodies  0.2  cm.  to  0.3  cm.  in  diameters.  Capsule  peels  with  difficulty.  Cortex  reduced 
and  replaced  by  these  cysts  which  appear  colloidal;  the  cortex  is  also  injected.     Pelves  negative. 

Liver  58J  oz.  (1610  gms.).     Nothing  of  note.     No  gall  stones. 

Pancreas.  Very  white  instead  of  yellow  and  a  curious  softness  unlike  the  usual  gland.  No  hemor- 
rhages. 

G astro-Intestinal  Tract. —  Negative  throughout.  Remains  of  hastily  eaten  vegetables  in  stomach. 
Well  distended,  few  rugae. 

Genito-Urinary  Tract. —  Bladder  external  wall  very  hemorrhagic;  inner  wall  clear.  Clear  fluid  in 
bladder.     Prostate  not  examined.     Testes  thread  well. 

Retroperitoneal  Tissues. —  Aorta  and  branches  smooth  and  elastic.  No  lymph  nodes  seen.  Marked 
hemorrhages  into  the  retroperitoneal  tissues. 

Head. —  Hair  brown,  cropped  on  right.  No  marks  on  inner  side  of  scalp.  Calvarium  thick;  frontal 
\  in.  (0.6  cm.);  temporal  J  in.  (0.3  cm.);  occipital  |  in.  (0.9  cm.).  Not  much  diploe.  Dura  thickened 
but  not  adherent.  Pia  thin  and  delicate.  Convolutions  simple  and  wide,  in  every  location.  General 
feeling  of  "normalness"  to  fingers,  slightly  putty-like  at  base.     No  atrophy  nor  gliosis. 

At  the  base,  a  slight  amount  of  meningitis  bends  the  optics,  the  circle  of  Willis  and  the  3rd  nerve 
together.  Tips  of  olfactory  bulbs  adherent  to  skull.  Optic  nerves  slightly  edematous  but  smaller  than 
normal.    Ganglions  and  pituitary  negative.     Ears  and  discs  not  examined. 

Brain  wt.  54  oz.  (1622  grams.).     Cord  not  removed. 

Anatomical  Diagnosis. 

Well  nourished.  Fractures  ribs,  left,  1st  rib. 

Abrasions,  head,  trunk,  extremities.  Slight  adhesive  pleuritis. 

Bruises,  extremities.  Pulmonary  congestion. 

Subperitoneal  hemorrhages.  Enlarged  thyroid. 

Free  blood  in  peritoneal  cavity.  Cystic  kidneys. 

Mesenteric  hemorrhages.  Hemorrhagic  cystitis  (bladder  wall). 

Intercostal  hemorrhage.  Retroperitoneal  hemorrhages. 

Fractures  ribs,  right  anterior  2nd,  7th,  8th,  Normal  brain. 

9th,  10th.  Slight  edema  optic  nerves. 

Fractures  ribs,  right  posterior  3rd,  4th,  5th,  Brain  weight  1622  gms. 

6th,  7th,  8th,  10th,  and  11th.  (Tigges'  formula  1424.) 


WAVERLEY   RESEARCHES.    II. 


c)     Special  Anatomical  Description  of  Brain. 


99 


The  brain  of  this  case  is  large  and  suits  the  dolichocephalic  skull.  The  orbital  frontal  angle  made 
between  the  basal  and  lateral  aspects  of  the  frontal  lobe  is  unusually  prominent  throughout.  The  occi- 
pital lobes  exhibit  a  slight  degree  of  asymmetry;  the  inferior  parietal  lobules  are  slightly  more  prominent 
than  the  surrounding  tissues. 

The  intermediate  precentral  area  has  the  "coronal"  type  of  construction.  The  gyri  are  in  general 
of  good  width  and  of  fairly  simple  pattern.  The  summits  of  the  gyri  do  not,  as  a  rule,  well  approximate; 
in  many  places  the  summits  do  not  lie  in  the  same  plane;  this  gives  the  brain  surface  a  motley,  irregular 
configuration,  somewhat  suggestive  of  foothills. 

The  corpus  callosum  is  of  a  good  depth  except  in  the  posterior  third  where  it  is  comparatively  nar- 
row.    There  appears  to  be  no  middle  commissure. 

The  pia  mater  is  slightly  thickened  and  hazy  throughout  and  the  arachnoidal  villi  are  moderately 
well  developed  along  the  vertex  of  the  superior  longitudinal  fissure.  There  are  small  pinpoint  white 
nodules  in  the  pia  mater,  especially  over  the  sulci,  chiefly  in  the  region  of  the  superior  parietal  lobule. 

d)     Microscopic  Examination. 

An  abstract  of  the  most  important  findings  yet  made  is  as  follows :  — 

Subpial  gliosis  is  nowhere  in  evidence.  Gliosis  of  the  white  matter  is  found  in  a  number  of  areas, 
precentral,  postcentral,  temporal,  occipital,  frontal,  but  is  nowhere  marked.  There  is  no  perivascular 
gliosis  except  for  a  slight  amount  in  the  section  over  the  right  prefrontal  region.  Satellitosis  is  nowhere 
noted. 

The  fiber  stains  show  no  notable  variation  from  the  normal  (as  judged  by  drawings  in  Campbell's 
"Localization  of  Cerebral  Function"),  except  that  a  section  from  the  right  superior  temporal  gyrus 
shows  some  diffuse  thinning  of  radiary  fibers;  but  even  this  appearance  may  possibly  be  regarded  as 
artificial.  We  have  not  regarded  the  presence  of  knoblike  enlargements  along  the  course  of  the  fibers 
as  of  pathological  significance. 

As  might  be  expected  from  the  nerve  fiber  and  glia  appearances,  the  nerve  cell  pictures  are  not  far 
from  normal  upon  qualitative  examination.  There  are,  however,  a  number  of  stratigraphical  appear- 
ances consistent  with  the  hypothesis  of  arrest  of  development.  Thus  the  supragranular  layers  of  the 
precentral,  postcentral  and  frontal  regions  are  not  definitely  laminated. 

The  evidences  of  cell  loss  or  numerical  hypoplasia  in  the  supragranular  layers  is,  as  a  rule,  confined 
to  the  lower  portions  of  these  layers.  The  granular  layers  are,  as  a  rule,  distinct,  where  they  are  nor- 
mally distinct  and  in  general  of  a  normal  appearance,  unless  we  regard  the  cells  as  slightly  thinned  out 
in  some  places  (right  upper  postcentral,  right  superior  parietal). 

The  infragranular  layers  show  apparent  scarcity  of  cells  in  a  number  of  regions,  for  example,  pre- 
central, postcentral,  occipital,  superior  parietal. 

The  above  description  suggests  a  certain  irregularity  in  the  distribution  of  the  hypoplasia.  The 
area  which  more  than  any  other  shows  architectural  disturbance  appears  to  be  illustrated  by  a  section 
from  the  right  superior  frontal  region.  The  cortex  here  shows  a  narrow  plexiform  layer  but  underneath 
a  complete  absence  of  distinct  lamination.  The  granular  layer,  for  example,  is  nowhere  distinct.  The 
scarcity  of  cells  seems  to  be  a  definite  one  and  of  a  convincing  degree.  The  cells  that  persist  show  a 
variety  of  staining  reaction  —  many  of  the  cells  have  a  pale  and  finely  granular  protoplasm.  On  the 
other  hand  a  good  many  cells  contain  perfectly  staining  Nissl  granulations;  there  is  a  moderate  degree 
of  phagocytosis  in  the  perivascular  spaces  in  this  area  and,  as  above  noted,  a  slight  cellular  gliosis  in  the 
white  matter. 


100  SOUTHARD  AND  TAFT. 

The  sections  stained  for  the  demonstration  of  neuroglia  fibrils  fail  to  show  any  convincing  increase 
thereof.  The  Weigert  myelin  sheath  stains  are  negative  as  to  nerve  fiber  change.  The  prefrontal 
cortex  on  the  right  side  shows  an  even  more  marked  scarcity  of  cells. 

A  type  of  problem  is  brought  up,  for  example,  by  a  section  from  the  right  upper  postcentral  region. 
Here  there  is  a  number  of  giant  pyramidal  cells  suggesting  that  there  might  have  been  an  error  in  the 
labelling  of  the  section  and  that  it  had  been  mistaken  for  a  section  of  precentral  cortex.  On  the  other 
hand,  the  supragranular  layer  in  the  cortex  here  sectioned  is  much  more  like  the  postcentral  cortex  and 
there  seems  to  be  no  reason  for  supposing  that  in  this  case  there  was  a  mislabelling  of  sections. 

A  section  from  the  right  intermediate  postcentral  gyrus  shows  an  unusual  tendency  to  the  grouping 
or  bunching  of  nerve  cells  in  compact  nests  containing  2-3-4  cells;  sometimes  the  nerve  cells  are  found 
overlying  each  other  slightly. 

In  a  section  from  the  right  superior  occipital  area,  a  number  of  dislocated  ganglion  cells  are  found  a 
good  way  into  the  white  matter.  One  of  these  dislocated  cells  was  found  with  two  nuclei.  On  the 
whole,  however,  in  this  case  there  are  not  many  instances  of  dislocated  ganglion  cells  in  the  white  matter. 

e)     Anatomical  and  Histological  Summary. 

The  brain  of  this  imbecile  of  39  years  weighed  1622  grams,  as  is  perhaps  consistent  with  his  belonging 
to  what  is  sometimes  termed,  for  practical  purposes,  the  able-bodied  or  colonial  type  of  feeble-minded. 
The  corpus  callosum  is  of  good  depth  except  for  a  narrow  place  in  the  posterior  third.  Microscopically 
we  failed  to  secure  evidence  of  gliosis  in  the  subpial  region  nor  marked  evidence  of  gliosis  in  any  locus. 
In  particular,  there  was  no  evidence  of  satellitosis.  Accordingly  we  may  regard  this  case  as  without 
evidence  of  active  phenomena,  whether  inflammatory,  sclerotic,  neuronophagic.  There  was  one  region 
in  which  there  was  a  moderate  degree  of  phagocytosis  in  the  perivascular  spaces.  This  region,  the  right 
superior  frontal,  was  interestingly  enough  the  region  in  which  occurred  the  most  marked  architectural 
disturbance  with  a  complete  absence  of  distinct  lamination. 

This  brain,  accordingly,  shows  one  of  the  purest  examples  yet  seen  of  uncomplicated  irregular  arrest 
of  development  with  stratigraphical,  architectural  alterations  (right  superior  frontal,  right  upper  post- 
central, dislocated  ganglion  cells,  right  superior  occipital)  without  complications  of  acquired  disease. 


Synopsis  of  Findings  of  Case  X. 
a)  Clinical. 

1.  Physical  Examination.—  Patient  was  born  Oct.  3, 1876;  admitted  Feb.  17,  1887;  died  of  pella- 
gra, Nov.  17,  1914.  Patient  was  slenderly  built,  and  well  nourished  up  to  two  years  before  his  death, 
when  pellagra  set  in.  From  the  autopsy  findings,  some  points  concerning  the  physique  of  the  patient 
may  be  taken.  The  nose  was  saddleshaped  and  the  head  narrow,  dolichocephalic,  eyes  small,  ears  irreg- 
ular with  adherent  lobules,  prominent  abdomen.  The  patient  was  never  very  strong  and  had  a  poor 
circulation  so  that  he  could  be  kept  out  of  doors  only  in  the  warm  weather. 

2.  Family  History. —  The  father  was  a  native  American,  25  years  of  age  at  the  birth  of  the  child. 
The  mother  was  born  in  Canada,  and  was  20  years  of  age  at  the  birth  of  the  child.  She  had  had  one 
child  before  the  birth  of  the  patient,  and  has  had  two  since  without  evidence  of  physical  deformity  or 
mental  deficiency.  There  is  no  history  of  mental  disorder  in  the  family.  There  was  nothing  unusual 
about  the  pregnancy  or  delivery. 

3.  Personal  Developmental  History. —  The  patient  began  to  walk  at  two  years;  was  not  able  to 


WAVERLEY  RESEARCHES.    II.  101 

talk,  and  is  described  as  having  been  of  a  passionate  temper.  Late  in  talking;  could  say  very  few  words 
at  time  of  admission. 

4  and  5.  School  Progress  and  Examinations.— There  was  improvement  physically  when  the 
patient  was  placed  in  the  outdoor  classes. 

6  and  7.  Practical  Knowledge  and  Efficiency.—  Patient  could  carry  stones,  use  a  grubhoe,  carry 
bundles,  and  rub  floors. 

8.  Social  History  and  Reactions. —  Patient  had  a  quick  temper  and  would  attack  people  who 
got  in  his  way.  On  account  of  his  tendency  to  cruelty  to  weaker  subjects,  he  was  kept  with  the  older 
boys.     He  could  say  a  few  words,  could  not  talk  in  sentences,  but  used  profane  and  obscene  phrases. 

9.  Moral  Reactions. —  Patient  was  more  or  less  irritable,  violent,  inclined  to  be  noisy,  and  as  above 
stated  would  attack  persons.     Masturbation. 

10.  Psychological  Tests. —  Binet  test  made  in  1914  showed  the  patient  to  be  2.4  years  of  mental 
age. 

Waverley  School  History. —  The  patient  grew  more  and  more  troublesome  as  he  grew  older,  becom- 
ing noisy  and  more  untidy.  In  his  thirty-seventh  year,  the  patient  began  to  lose  weight  and  became 
emaciated,  and  developed  a  peculiar  skin  eruption  on  the  back  of  the  neck  and  extensor  surfaces  of  the 
hands.  The  eruption  was  symmetrical  and  was  regarded  as  pellagra.  This  eruption  healed  with  stimu- 
lating ointments,  and  the  patient  grew  physically  somewhat  better.  Later  the  eruption  returned  and, 
despite  outdoors  treatment,  a  decubitus  developed,  finally  covering  a  portion  as  large  as  a  dinner  plate, 
with  great  destruction  of  tissue  and  offensive  odor. 

b)    Autopsy. 

Body  of  a  slenderly  built  and  poorly  developed  white  male,  144  cm.  in  length.  Skin  is  yellowish 
grey  except  over  the  face  where  it  is  diffusely  pigmented  (freckles)  and  over  the  exposed  portions  of  the 
head  where  the  hair  sparsely  grows  (frontotemporal  region) :  here  it  is  a  deep  brown  color  with  crackled 
lines  alternating  with  patches  of  white.  This  condition  is  especially  marked  in  the  back  of  the  neck 
extending  as  far  backward  as  the  7th  cervical  vertebra  where  it  is  abruptly  replaced  by  normal  appearing 
skin.  The  hands  are  brown,  especially  over  the  knuckles  where  the  skin  is  scaling,  so  much  that  it  may 
be  lifted  from  the  pale  true  skin.  This  pigment  is  apparent  on  the  hands  up  to  the  wrists  and  extending 
in  a  gauntlet  shape  4  cm.  above  the  wrist  where  it  also  fades  from  this  diffuse  and  dense  color  into  iso- 
lated pigmentation  (freckles)  that  gradually  become  less  until  the  axillary  region  is  reached.  There  are 
some  scattered  freckles  over  the  chest  and  abdomen  and  upper  thighs. 

Over  the  mid-shin  region  of  both  legs  there  are  brawny  brown  areas  measuring  8X4  cm.  and  12  X 
6  cm.  There  is  a  bruise  measuring  3X2  cm.  over  the  anterior  surface  of  the  right  mid-thigh;  another 
4  cm.  above  left  patella. 

There  are  gangrenous  areas  on  the  skin  over  the  posterior  portion  of  the  right  shoulder,  measuring 
4X3  cm.,  over  the  right  trochanter  major  measuring  12  X  10  cm.  This  is  markedly  sloughing  and 
extends  deeply  into  the  muscular  substance.  Probing  this  muscular  substance,  a  soft,  mushy,  non- 
resisting  tissue  appears  in  the  place  of  the  normal  firm  resisting  muscular  tissue. 

A  similar  area  over  the  left  trochanter  major  measures  8X6  cm.  over  the  left  shoulder,  another 
measures  4X5.  Also  in  the  inner  surface  of  each  knee  similar  areas  vary  in  size  from  3X4  cm.  —  IX 
1  cm.  and  0.8  X  1  cm.  in  diameter. 

A  few  scattered  hairs  over  upper  sternal  region.  Pubic  hair  more  or  less  triangular  in  shape,  grows 
in  a  straight  line  to  the  ensiform;  hair  also  grows  on  inner  thighs,  also  legs  and  forearms.  There  is 
scanty  evidence  of  hair  over  face. 

Nose  slightly  saddle  shape  with  broad  bridge  and  small  alae. 

The  pupik  are  dilated  and  unequal;   the  right  measures  0.7  cm.,  the  left  0.6  cm.     The  lips  show 


102  SOUTHARD  AND  TAFT. 

sordes.     The  teeth  are  poor  and  there  is  a  bloody  fluid  between  them.     (Some  report  of  sore  mouth  previ- 
ous to  death). 

Ventral  section. —  Fat  over  abdomen  1.0  cm.,  over  thorax,  0.5  cm.  Muscles  pinkish.  Peritoneum 
is  grey. 

Liver. —  6  cm.     Stomach  8  cm.     Transverse  colon  15  cm.  below  the  ensiform. 

The  omentum  is  very  rich  in  fat  and  covers  intestines  completely.  Intestines  are  injected  and  slip- 
pery to  the  touch.  The  appendix  measures  approximately  4  cm.  and  is  large  at  its  distal  end.  The 
bladder  is  not  distended.  There  is  a  little  free  fluid  in  the  abdominal  cavity.  The  mesenteric  lymph  nodes 
not  enlarged.  Spleen  exceedingly  large.  Diaphragm  arches  to  the  third  rib  on  the  right  and  to  the  5th 
on  the  left. 

Thorax. —  Lungs  adherent  to  the  chest  wall  in  the  mid-anterior  portion.  There  is  no  free  fluid  in 
the  pleuric  cavities.     Pericardial  sac  contains  slight  traces  of  fluid. 

Heart. —  Assumes  a  circular  shape  on  being  removed.  It  is  very  flabby  and  it  would  be  difficult 
to  tell  which  were  the  left  side  on  inspection.  The  descending  branch  of  the  left  coronary  is  smooth  and 
delicate,  as  is  the  right  coronary.  Myocardium  is  pale  and  flabby  and  not  friable.  Valves  are  negative 
except  the  aortic  which  shows  a  sessile  red  adherent  body  clinging  to  the  middle  of  the  posterior  cusp 
measuring  approximately  0.8  X  0.6  cm.     No  other  vegetations. 

Approximate  measurements:   TV   8.0  cm.     PV  5.0  cm.     LV  0.9  cm. 

MV  9.0  cm.     AV  8.0cm.    RV  0.3  cm. 

The  intima  of  the  aorta  is  very  red  and  firm. 

Lungs. —  No  weights  taken.  Right  lung  has  but  two  lobes.  The  upper  is  normal;  the  lower  is 
injected  on  lateral  surface  and  on  section  there  is  reddening  of  the  lung  tissue  superficially.  Bronchi 
are  covered  by  reddish  thin  fluid.  Left  lung  is  markedly  congested  in  the  posterior  portion.  Pleura 
has  been  torn  on  removal  of  lung  but  there  is  no  raised  area  around  the  bronchi  at  that  point.  There  is 
a  small  area  not  more  than  3  cm.  in  diameter  where  the  bronchi  have  induration  about  them  in  the 
central  portion  of  the  lower  lobe.     Bronchi  reddened  throughout. 

Organs  of  the  Neck. —  Not  removed. 

Abdomen. —  Spleen:  Markedly  large;  measures  approximately  14  X  10  X  4  cm.  Capsule  not 
thickened  but  dark  areas  (?).  Hemorrhages  show  through  the  capsule.  On  section  the  pulp  is  very  soft, 
scrapes  heavily  and  the  malpighian  bodies  faintly  descernible.  The  pulp  swells  above  the  cortex  on 
section  and  there  are  greyish  pink  wedge  shaped  areas  with  their  bases  toward  the  capsule  that  show  red 
external  borders.     Trabecidae  indistinct. 

Adrenals. —  Small.  The  cortices  are  both  pale  yellow  edematous  and  fade  into  a  deeper  brown  at 
irregular  intervals.     The  central  portion  is  brown  and  there  is  no  softening. 

Kidneys. —  Fairly  well  supplied  with  fat.  Capsule  strips  easily  but  is  opaque.  The  cortex  measures 
0.6  cm.,  is  brilliantly  and  uniformly  injected  and  red  points  dot  the  intervascular  injections.  At  one 
point  there  is  a  bright  yellow-grey  wedge  shaped  body  occupying  the  cortex  for  a  space  of  1.5  X  0.6  cm. 
The  pyramids  are  poorly  differentiated,  look  yellow  in  their  centers.  Pelves  markedly  congested.  The 
other  kidney  not  so  injected  but  swells  over  capsule  on  section  and  on  stripping  the  capsule  the  kidney 
surface  is  pulled  away  at  two  points.     No  cysts  seen. 

Liver. —  Measures  approximately  20  X  18  cm.  The  surface  is  mottled  yellow  and  red.  Cut 
surface  swells  slightly  over  the  capsule.  Color  of  the  liver  on  section  is  not  remarkable;  shows  lobules 
well  marked  but  no  congestion.     The  gall  bladder  very  small;  contains  a  few  cc.  of  turbid  yellow  fluid. 

Pancreas. —  Not  examined. 

G astro-Intestinal  Tract. —  Stomach  dilated.  Swells  somewhat;  edematous;  no  rugae.  Mucous 
wall  drips  grey  fluid  and  the  wall  has  a  granular  and  somewhat  injected  appearance.  The  same  is  true 
of  the  lower  tract  but  no  ulcers  of  hemorrhagic  state  of  the  intestines  seen,  with  the  exception  of  focal 
areas  of  injection  in  the  upper  third  of  the  descending  colon.  The  content  of  the  entire  intestinal  tract 
and  particularly  the  colon  is  fluid  brown  yellow. 


WAVERLEY  RESEARCHES.    II. 


103 


Genito-Urinary  Tract. —  Bladder  negative.     Prostate  not  enlarged.     Testes  not  examined. 

Retro-Peritoneal  Tissues. —  The  lymph  nodes  are  not  present.  There  are  (?)  hemo-lymph  nodes 
along  the  aorta.  The  sympathetic  ganglia  small.  The  aorta  is  small  in  calibre  and  thin  walled.  The 
peripheral  nerves  negative. 

Head. —  The  cranium  is  narrow,  measures  52  cm.  in  circumference  and  the  hair  grows  scantily  over 
the  entire  scalp.  The  scalp  is  adherent  and  inelastic.  Caharium  is  dense  and  measures,  frontal  0.4  cm., 
temporal,  0.2  cm.,  0.4  cm.  and  occipital,  0.6  cm.  Grooving  for  the  middle  meningeal  arteries  very  narrow 
and  shallow  on  the  right.  The  dura  is  not  adherent  and  in  the  frontal  region  one  sees  the  convolutions 
through  it.  There  is  some  thickening  of  the  dura  in  the  middle  meningeal  distribution.  The  longitudinal 
sinus  free.  The  dura  seems  dense  and  fills  the  cranium  cavity  except  in  the  frontal  portion  where  there 
is  a  space  between  the  frontal  portion  and  the  inner  table  sufficient  to  insert  three  fingers.  The  pia  mater 
is  somewhat  injected  over  the  vertex. 

The  brain  is  exceedingly  compact  and  firm. 

At  the  base  of  the  brain  a  striking  appearance  is  presented  by  the  depression  of  the  orbital  portion  of 
the  frontal  lobes  in  their  central  portions  and  the  marked  foreshortening  or  (?)  absence  of  the  prefrontal 
regions.  The  olfactory  bulbs  somewhat  softened.  The  optic  nerves  slightly  thinned  but  show  no  atrophy. 
The  pia  mater  over  the  cerebellum  is  markedly  thickened  and  opaque.  The  floor  of  the  4th  ventricle  is 
clear.  Pons  and  medulla  are  firm.  There  is  marked  pressure  pointing  over  each  lobus  pyriformis. 
The  3rd  ventricle  contains  a  quantity  of  clear  fluid  (specimen  taken  for  gold  reaction). 

The  superior  surface  of  the  brain  is  uniformly  firmer  than  normal,  there  being  no  points  of  softening 
or  change  in  consistency  with  the  exception  of  the  posterior  portion  of  the  left  angular  gyrus.  The 
convolutions  of  the  entire  surface  have  a  tendency  to  be  less  plump  on  the  crowns  than  is  normal;  this 
is  seen  particularly  on  the  right  side. 

The  occipital  lobes  somewhat  foreshortened  but  are  flush  with  the  cerebellum.  The  first  temporal  on 
the  right  is  slightly  wider  than  its  fellow  and  there  is  a  difference  in  the  winding  of  the  second  convolution. 

The  Gasserian  ganglia,  the  pituitary,  the  optic  discs,  middle  ears,  and  cord  negative  on  section. 

The  brain  weight  is  1450  grams. 

Anatomical  Diagnosis. 


Poorly  developed. 

Pellagra. 

Bruises,  extremities. 

Decubitus  (Shoulder  and  trochanter  major, 

knees.) 
Saddle  shaped  nose. 
Unequal  pupils. 
Sordes  on  lips. 
Teeth  poor. 
Induration  appendix. 
Chronic  fibrous  pleuritis. 
Acute  vegetative  endocarditis  (aortic  valve). 
Pulmonary  congestion;    beginning  bronchial 

pneumonia. 
Acute  bronchitis. 
Acute  splenitis. 
Infarct  spleen. 

(?)  Post  mortem  change  adrenals. 
Infarct  of  Kidney. 


Acute  parenchymatous  nephritis. 

Acute  hepatitis. 

Chronic  gastritis. 

Head  narrow. 

Scalp  adherent. 

Calvarium  dense. 

thin. 
Focal  thickening  of  dura. 
Injection  pia. 

Thickening  of  pia  cerebellum. 
Evidences  of  brain  swelling. 
General  cerebral  gliosis. 
Superficial  atrophy  convolutions  (flattening 

of   crowns). 
Inequalities  first  temporal  convolutions. 
Brain  weight  1450  gms. 
(Tigges'  formula  1152  gms.) 
Cord  not  remarkable. 


104 


SOUTHARD   AND   TAFT. 


c)     Special  Anatomical  Description  of  Brain. 


The  brain  in  general  suits  the  dolichocephalic  skull.  There  is  a  slight  occipital  asymmetry  such 
that  the  right  lobe  is  shorter  than  the  left,  deviates  somewhat  more  from  the  median  line  and  has  a  groove 
upon  the  posterior  extremity,  whereas  the  left  occipital  lobe  deviates  slightly  to  the  right  and  even  some- 
what overreaches  the  median  sagittal  plane  (the  posterior  extremity  of  the  left  occipital  lobe,  however, 
deviates  again  leftwards). 

The  gyri  of  this  brain  are  in  general  rather  narrow,  closely  approximated  except  at  the  borders  of 
the  summits.  The  corpus  callosum  is  of  good  width  except  for  a  somewhat  narrow  middle  third.  There 
is  no  evidence  of  the  middle  commissure.  The  cerebellum  projects  farther  backward  on  the  right  than 
on  the  left  (compare  contralateral  asymmetry  of  occipital  lobes).  The  cerebellum  suggests  in  general 
a  reduction  in  size  and  the  inferior  surface  of  the  cerebellum  shows  a  considerable  thickening  of  the  pia 
mater,  especially  over  the  incisure.     The  pia  mater  of  the  brain  in  general  is  slightly  thickened  and  hazy. 

d)     Microscopic  Examination. 

An  abstract  of  important  findings  is  as  follows :  — 

Subpial  gliosis  is  found  in  a  number  of  areas,  for  example,  focally  in  the  precentral  and  postcentral 
angular  gyrus;  but  in  other  areas  the  plexiform  layer  seems  to  be  normal.  The  white  matter  is  not,  as 
a  rule,  affected  by  gliosis,  although  the  angular  gyrus  of  superior  parietel  area  and  frontal  regions  show  a 
general  increase. 

Satellitosis  is  found  in  a  number  of  areas  (precentral,  occipital,  temporal  angular,  superior  parietal, 
prefrontal. 

The  Weigert  myelin  sheath  stains  show  a  certain  indistinctness  in  the  supraradiary  layers,  pre- 
central, postcentral,  temporal,  angular,  superior  frontal  (here  patchy).  A  good  deal  of  this  fiber  change 
might  be  within  the  limit  of  artefact. 

The  nerve  cells  show  numerical  hypoplasia  in  a  number  of  areas;  the  right  upper  precentral  area, 
for  example,  shows  very  few  cells  in  the  supragranular  region,  aside  from  the  outer  small  pyramids. 
This  condition  is  less  marked  in  the  postcentral  area  where  the  distinction  of  supra  and  infragranular 
layers  is  more  evident.  The  right  superior  temporal  region  shows  marked  cell  scarcity  and  the  arrange- 
ment of  the  cells  is  markedly  irregular.  The  supragranular  layer  of  the  right  angular  gyrus  is  narrow 
and  of  a  somewhat  abnormal  development.  The  infragranular  layer  here  shows  marked  thinning  out 
of  cells.  The  right  superior  parietal  area  shows  a  more  marked  architectural  disturbance  in  the  infra- 
granular region.     The  cells  of  the  second  supragranular  layer  are  also  much  thinned. 

The  right  superior  frontal  region  shows  marked  lack  of  cells  in  the  second  and  third  layers.  The 
prefrontal  region,  on  the  other  hand,  shows  fairly  well  developed  supra  granular  layers  with  a  few  foci 
here  and  there  of  thinning  out.  These  foci  affect  all  the  layers.  The  infragranular  layer  also  shows  a 
tendency  to  patchy  cell  loss.  This  case  being  one  of  Pellagra  shows  a  rather  rich  display  of  acute  nerve 
cell  changes,  with  excellent  examples  of  the  axonal  reaction  in  the  Betz  cells.  There  was  in  one  region 
(right,  upper  postcentral)  a  focus  in  which  there  were  a  few  round  cells  in  the  perivascular  spaces;  it 
could  not  be  made  out  that  these  were  definitely  lymphocytes  and  they  may  perhaps  be  regarded  as 
neuroglia  cells. 

e)     Anatomical  and  Histological  Summary. 

The  brain  of  this  case  in  an  idiot  or  low  imbecile  of  2-4.5  years,  Binet  age,  weighed  1450  grams,  and 
may  be  regarded  as  fairly  complex  in  construction.  The  grey  matter,  white  matter  and  corpus  callosum 
stand  in  fair  proportion  to  one  another,  except  that  the  gyri  of  the  brain  fail  to  approximate  along  the 
borders  of  their  summits  and  that  the  middle  third  of  the  corpus  callosum  is  narrow. 


WAVERLEY   RESEARCHES.    II.  105 

Subpial  gliosis  and  satellitosis  are  in  fairly  frequent  evidence,  but  there  is  little  or  no  affection  of  the 
white  matter  by  gliosis.  The  nerve  cell  pictures  show,  to  qualitative  judgment,  frequent  instances  of 
cell  scarcity  affecting  both  the  supra  granular  and  infra  granular  layers. 

The  following  is  a  brief  characterization  of  each  of  the  ten  cases  in  the  Waverley 
Research  Series,  which  may  be  helpful  for  quick  reference. 

Case  I.  The  brain  of  this  microcephalic  idiot,  of  a  mental  age  estimated  less  than 
one  year,  has  somewhat  the  suggestion  of  the  brain  of  an  ape.  A  good  portion  of  the  cere- 
bellum is  visible  from  the  dorsal  aspect  of  the  nervous  system.  Whatever  the  cause  of 
microcephaly,  the  fact  that  an  elder  sister  of  this  patient  was  almost  equally  deficient  and 
almost  identically  microcephalic,  must  be  taken  into  account,  as  well  as  the  fact  that 
other  children  before  and  after  the  microcephalic  pair  seem  to  have  been  normal,  or  at  all 
events  not  microcephalic.  The  mentality  of  this  case  was  undoubtedly  the  lowest  of  our 
series. 

Case  II.  Also  microcephalic,  this  case  presents  a  combination  of  microcephaly  with 
a  high  degree  of  internal  hydrocephalus.  This  hydrocephalus  is  one  doubtless  ex  vacuo, 
being  very  possibly  due  to  an  early  non-syphilitic  (poliomyelitic?)  infection  at  three  months 
of  age.  The  detailed  description  will  show  how  well  preserved  was  the  vision  of  this  case, 
functionally  speaking,  despite  the  remarkable  cystic  condition  and  microgyria  of  the 
posterior  portion  of  the  cerebrum.  In  point  of  fact,  the  visuo-sensory  portion  of  the 
cortex  appears,  however,  to  have  been  preserved,  and  the  tremendous  lesion  to  be  noted 
on  the  upper  aspect  of  the  parieto-occipital  regions  did  not  take  effect  upon  the  elementary 
visual  functions  of  the  cortex.  The  case  is  evidently  one  of  focal  brain  lesion,  and  very 
probably  belongs  in  what  Tredgold  would  call  the  group  of  "secondary  amentia."  Of 
course  it  is  possible  that  the  microcephaly  was  in  some  sense  an  example  of  primary  amentia 
and  that  the  focal  posteriorlying  lesions  with  compensatory  hydrocephalus  were  due  to 
intercurrent  disorder.  It  is  possible,  accordingly,  that  this  case  may  be  one  of  a  combina- 
tion of  primary  and  secondary  amentia. 

Case  III.  The  brain  of  this  microcephalic  imbecile  was  so  small  (610  grams)  that 
any  coarse  arrangement  of  the  brains  of  the  present  series  (Cases  I-X)  must  naturally 
show  "Zip's"  brain  lower  than  his  actual  capacity  would  have  warranted.  It  is  stated 
that  this  patient  knew  how  to  read  and  write  a  little.  Although  unable  to  support  himself 
he  had  lived  most  of  his  years  outside  of  institutions,  being  a  harmless,  amiable  vagrant. 
With  some  hesitation,  he  may  perhaps  be  placed  among  the  imbeciles.  Microscopic 
study  indicates  a  special  thinning  of  cells  in  the  frontal  and  parietal  regions  as  well  as  a 
degree  of  gliosis  in  the  outermost  layer  of  the  cortex  and  below  the  appendema  of  the 
ventricles.     The  corpus  callosum  was  well  preserved  and  of  a  good  size  in  proportion  to  the 


106  SOUTHARD  AND   TAFT. 

brain.  Microscopically  the  case  will  form  an  excellent  foil  to  Case  I,  a  case  of  far  less 
intelligence,  but  the  microscopy  is  complicated  by  gliosis,  whose  age  is  difficult  to  determine. 
(In  this  connection,  it  must  be  remembered  that  the  patient  is  said  to  have  had  an  epileptic 
attack  at  one  time.)  Although  the  brain  at  first  sight  seems  a  good  instance  of  a  brain 
in  miniature,  and  although  the  frontal  and  temporal  regions  are  fairly  uniform,  the  parietal 
and  occipital  lobes  are  quite  asymmetric,  especially  in  that  the  right  occipital  lobe  is 
considerably  shorter  than  the  left;  there  is  a  suggestion  of  an  Affenspalte  on  the  right  side. 

Case  IV.  This  case  is  the  oldest  of  the  series  (62  years),  being  an  old  almshouse  case, 
apparently  of  feeble-mindedness,  of  unknown  grade  but  apparently  far  higher  than  that 
of  any  other  member  of  the  series  (except  V,  with  the  question  of  dementia  praecox,  and 
VIII,  the  executed  murderer).  It  is  of  course  possible  that  this  case  is  an  old  dementia 
praecox  (compare  hallucinations  observed  at  Dan  vers  Hospital).  The  corpus  callosum 
was  rather  thinner  than  normal;  the  brain  weighed  1340  grams  at  death.  Throughout  the 
brain,  in  different  places,  there  were  various  degrees  of  gliosis  and  satellitosis.  This  was 
especially  marked  in  the  left  and  right  prefrontal  regions.  The  whole  brain  suggested  a 
slight  degree  of  atrophy  (slight  sulcal  flaring).  There  was  a  slight  asymmetry,  partic- 
ularly of  the  poles  of  the  brain;  the  parietal  region  shows  a  tendency  to  microgyria,  and 
the  right  pyriform  lobule  is  larger  and  more  prominent  than  the  left.  There  is  a  marked 
dilatation  of  the  lateral  ventricles  except  the  descending  horns.  The  gross  appearance  of 
the  brain  must  be  admitted  to  be  entirely  consistent  with  the  hypothesis  of  dementia 
praecox;  yet  the  case  is  a  good  instance  of  the  so-called  old  demented  imbecile  found  in 
almshouses  and  is  of  value  in  this  series  for  comparison  with  others. 

Case  V.  Case  V  falls  in  a  group  with  Cases  IV  and  VIII  as  of  higher  intelligence 
than  any  of  the  others  in  the  present  series  (Cases  I-X).  It  is  possible  that  the  original 
intelligence  of  Case  V  was  higher  than  that  in  Case  VIII,  and  highly  probable  that  it 
was  higher  than  that  in  Case  IV.  The  case  is  interesting  as  showing  the  outcome  of  a 
truant  high  school  boy  existence.  It  is  probable  that  the  patient  was  a  moron,  or  at  all 
events  a  subnormal  subject  and  perhaps  belongs  in  the  delinquent  group.  The  unilateral 
moderate  hydrocephalus  is  not  infrequent  in  dementia  praecox.  The  left  frontal  and  right 
occipital  lobes  show  contralateral  asymmetry,  being  narrower  than  their  fellows.  The 
right  occipital  atrophy  or  aplasia  appears  to  centre  in  the  second  gyrus.  The  corpus 
callosum  in  this  case  is  of  a  good  size.     The  brain  weighed  1335  grams. 

Case  VI.  This  case  is  that  of  an  idiot  of  two  years  mental  age,  who  seemed  to  combine 
the  typical  features  of  idiocy  in  such  a  way  as  to  be  a  case  par  excellence  for  clinical  demon- 
stration. The  brain,  weighing  1130  grams,  shows  the  smallest  brain  weight  of  our  series 
outside  the  group  of  pronounced  microcephalic  cases.     The  brain  is  of  very  simple  construe- 


WAVERLEY   RESEARCHES.    II.  107 

tion.  The  histological  examination  showed  in  this  case,  as  in  Case  VII,  the  occurrence  of 
the  so-called  "rod  cells"  in  the  cortex.  These  cells,  characteristic  of  general  paresis  when 
associated  with  the  exudative  and  destructive  changes  found  therein,  are  not  to  be  inter- 
preted as  necessarily  indicating  syphilis  when  they  occur  alone.  Perhaps  they  indicate 
merely  proliferating  vascular  changes  or  proliferations  of  unknown  nature  of  mesenchymal 
tissue.  There  is,  however,  a  suspicion  of  syphilis  in  the  antecedents  of  this  almshouse 
transfer  case,  and  certain  "tissue  paper"  scars  found  on  the  skin  at  autopsy  may  add  to  the 
suspicion  that  this  may  be  a  case  of  congenital  syphilis  of  a  non-exudative  type.  It  is  also 
possible  that  good  fortune,  or  a  still  more  minute  microscopic  examination  than  we  have 
been  able  to  perform,  would  reveal  exudative  changes  at  some  point.  Another  feature  of 
the  greatest  interest  in  Case  VI  is  the  virtual  absence  of  one  vocal  cord  as  demonstrated 
at  the  autopsy.  This  fact  may  serve  to  illustrate  the  difficulties  of  proper  interpretation 
in  routine  cases.  In  this  case,  for  instance,  the  aphasia  could  not  be  taken  to  be  necessarily 
of  nervous  origin. 

Case  VII.  Like  the  brain  of  Case  VI,  the  brain  of  Case  VII  showed  rod  cells.  With 
respect  to  the  possibilities  of  syphilis  in  the  family,  it  is  important  to  consider  that  of  five 
children,  three  of  the  children  were  dead  (two  of  marasmus),  and  that  the  mother  was 
subject  to  fainting  fits.  A  great  variety  of  anomalies  in  the  body  is  probably  entirely 
consistent  with  the  hypothesis  of  syphilis.  There  was  a  certain  irregularity  in  the  mental 
capacities  of  the  case,  which  should  also  be  regarded  as  thoroughly  consistent  with  this 
hypothesis.  Thus  the  case,  classified  as  an  imbecile  with  a  mental  age  of  five,  seemed  in 
a  number  of  respects  not  to  reach  above  the  highest  grade  of  idiocy,  or  a  lower  grade  of 
imbecility  than  the  mental  age  would  superficially  indicate.  There  was  some  sensory 
disorder  in  the  case  as  well.  Accordingly,  both  VI  and  VII  are  cases  which  bring  up  the 
question  of  congenital  syphilis  of  a  character  not  so  destructive  or  progressive  as  cases 
of  exudative  syphilis  (of  the  group,  for  example,  of  juvenile  paresis)  would  be.  To  be 
sure,  the  rod  cells  indicate  a  certain  activity  and  progressiveness  on  the  part  of  the  disease. 
Theoretically  and  academically,  at  any  rate,  these  cells  may  indicate  that  conditions  are  not 
so  entirely  stationary  in  the  nervous  system  as  we  are  led  theoretically  to  suppose  should 
be  the  case  in  the  brains  of  the  feeble-minded. 

Case  VIII.  This  belongs  with  Cases  IV  and  V,  amongst  those  of  highest  intelligence 
in  the  present  series  (Cases  I-X).  The  case  was  that  of  an  executed  murderer.  The 
brain  was  viewed  on  anatomical  grounds  to  be  that  of  a  defective  before  there  was  any 
clinical  confirmation  or  knowledge  of  the  fact.  The  gyri  were  noted  to  be  of  a  generally 
transverse  direction.  There  was  a  lack  of  complete  longitudinal  sulci  in  the  frontal  lobes. 
A  blunting  of  the  frontal  lobes  was  possibly  the  most  convincing  suggestion  of  the  probable 


108  SOUTHARD   AND  TAFT.       . 

clinical  deficiency  on  the  part  of  the  subject.  The  parietal  region  was  relatively  and 
absolutely  well  developed.  There  was  an  asymmetry  of  the  pyriform  lobules,  to  some 
extent  of  the  entire  hippocampal  lobule.  The  corpus  callosum  was  of  good  size  though 
there  was  a  question  whether  it  might  not  be  regarded  as  somewhat  thinned  out  posteriorly. 
It  seems  safe  to  regard  this  case  as  either  in  the  moron  group  or  as  at  any  rate  to  some 
degree  subnormal. 

Case  IX.  Case  IX  illustrates  the  "ablebodied"  type  of  imbecile  (mental  age,  7). 
The  weight  of  the  brain  in  this  case  was  even  in  excess  of  what  it  should  have  been  by 
Tigges'  formula;  namely:  1622  grams,  as  against  1424  by  Tigges'  formula.  (It  is  true 
that  the  violent  death  of  this  patient  may  have  led  to  a  certain  congestion  of  the  brain 
which  artificially  increased  its  weight.)  The  brain  of  Case  IX,  quantitatively  adequate 
as  it  would  seem,  was  a  brain  which  must  strike  the  anatomist  as  of  exceedingly  poor 
mould. 

Case  X.  The  brain  weight  in  Case  X  was  also  high,  being  1450  grams,  and  in  point 
of  fact  298  grams  in  excess  if  we  should  trust  Tigges'  formula.  He  is  described  as  of  a 
very  excitable  nature.  The  brain  shows  a  very  considerable  degree  of  hydrocephalus. 
Attention  may  be  called  to  some  theoretical  points  concerning  hydrocephalus  in  these 
cases  in  a  special  section  devoted  to  this  topic.  Case  X,  like  Case  VII,  was  of  the  excitable 
group,  and  the  brain  of  Case  VII  also  showed  hydrocephalus,  which  likewise  does  not 
seem  to  be  explicable  on  the  basis  of  a  compensatory  condition  (ex  vacuo,  as  illustrated  by 
Case  IV),  or  an  anomaly  of  the  dementia  praecox  group  (as  illustrated  by  Case  V). 


III. 


NEUROPATHOLOGICAL  CORRELATIONS   WITH   CLINICAL  AND 

PSYCHOMETRIC  FINDINGS   IN  FEEBLE-MINDEDNESS 

(WAVERLEY  RESEARCH   SERIES,   CASES  I-X). 

E.  E.  Southard  and  Annie  E.  Taft. 


III. 

NEUROPATHOLOGICAL  CORRELATIONS  WITH  CLINICAL  AND 

PSYCHOMETRIC  FINDINGS  IN  FEEBLE-MINDEDNESS 

(WAVERLEY  RESEARCH  SERIES,  CASES  I-X.) 

E.  E.  Southard  and  Annie  E.  Taft. 

The  province  of  the  present  article  is  limited.  We  intend  to  make  a  provisional 
epicritical  review  of  the  problems  presented  by  the  first  ten  cases  (I-X)  of  the  Waverley 
Research  Series  of  cases  of  feeble-mindedness.  This  term  we  use  to  include,  not  only 
feeble-mindedness  proper  (i.  e.,  the  so-called  morons  of  recent  American  nomenclature), 
but  also  the  subnormal  persons  above  the  grade  of  morons,  which  modern  research  is 
bringing  into  the  field  of  feeble-mindedness,  and  also  the  imbeciles  and  idiots  which  lie 
below  the  grade  of  moron  or  of  the  feeble-minded  proper.  It  is  the  plan  of  the  present 
series  of  anatomical  examinations,  therefore,  to  work  up  successively  a  series  of  all  types 
and  grades  of  feeble-mindedness  and  subnormality  without  undue  regard  to  their  clinical 
classification  or  intelligence  grading.  Already,  however,  the  data  of  our  first  ten  cases 
have  suggested  certain  lines  of  correlation  which  it  seems  worth  while  to  set  down  here  in 
the  guise  of  provisional  hypotheses. 

Among  all  the  problems  sketched  above  (problems  of  the  schools,  the  courts,  the  social 
agencies,  the  eugenics  record  offices,  the  biological  laboratories,  and  the  like),  perhaps  no 
problem  is  more  acute  than  that  of  the  significance  and  possible  future  of  mental  tests  after 
the  manner  of  Binet.  We  must  leave  to  the  psychologists  the  evaluation  of  the  details 
of  these  tests  and  the  construction  and  choice  of  new  variants.  We  must  leave  to  those 
versed  in  the  statistics  of  mental  measurement  the  decision  how  far  the  age  level  of  the 
Binet  tests  and  the  percentage  level  of  the  Yerkes  tests  apply  to  actual  conditions.  We 
must  concede  forthwith  that  Binet  left  but  a  torso  of  what  the  future  has  in  store  in  the 
shape  of  mental  tests,  and  we  may  concede  that  these  tests,  for  the  most  part,  yield  little 
information  as  to  those  emotional  and  volitional  impulses,  instincts,  and  sentiments  which 
are  so  important  in  social  life.  On  the  whole,  however,  it  is  generally  admitted  that  progress 
is  being  made  to  a  more  and  more  accurate  measurement  of  mental  capacities  of  certain  sorts. 
This  bit  of  progress  is  enough  to  brighten  the  path  of  the  anatomist.  The  anatomist  feels 
that  he  must  follow  far  in  the  rear  of  the  psychologist  and  physiologist  in  his  analysis;  par- 
ticularly in  his  analysis  of  deviations  and  perversions  which  are  of  a  qualitative  nature  or 
cannot  readily  be  reduced  to  quantitative  values.     When,  however,  the  anatomist  learns 


112  SOUTHARD  AND  TAFT. 

that  psychometry  is  not  merely  an  idle  dream,  but  that  distinct  losses, —  when,  at  any 
rate,  these  losses  are  of  large  degree, —  are  demonstrable  and  to  a  certain  extent  measura- 
ble, his  hope  is  kindled  that  the  brain  itself  may  unexpectedly  at  least  yield  up  a  set  of 
useful  correlations. 

What  is  the  relation  of  mind  to  brain?  Speculation  halts  shortly  before  the  intricacies 
of  this  problem  when  it  is  taken  as  a  problem  of  the  relation  of  the  full-blown,  healthy  mind 
with  the  entirely  normal,  richly  active  brain.  Important  light  is  thrown  upon  the  topic, 
of  course,  by  the  anatomo-clinical  method  which  yielded  such  rich  data  in  the  last  half 
of  the  nineteenth  century;  for  by  this  method  definite  losses  of  brain  substance  were  often 
found  to  be  associated  with  equally  definite  losses  of  mental  power.  The  limitations  of 
this  method  are  numerous  and  need  not  detain  us.  The  method  has  not  been  exhausted; 
but  its  future  fruits  depend  upon  elaborate  tissue  analyses  which  the  ordinary  laboratory 
and  the  ordinary  scientific  leisure  available  under  our  present  institutional  system  do  not 
permit.  Almost  equally  rich  results  have  accrued  from  work  in  comparative  anatomy, 
latterly  supplemented  by  behavioristic  studies. 

What  we  at  present  need  is  to  supplement  the  methods  of  normal  neurology  and 
psychology,  the  methods  of  anatomo-clinical  research,  and  the  methods  of  comparative 
anatomy  with  a  method  which  has  alliances  with  each  of  these  but  seems  to  us  to  contain 
certain  elements  of  novelty.  It  would  be  strange  if  the  field  of  anatomy  in  feebleminded- 
ness were  not  full  of  novelty  since  it  had  been  so  poorly  tilled  heretofore.  The  novelty  in 
the  anatomic  situation  with  respect  to  feeble-mindedness  seems  to  us  to  lie  in  the  fact 
that  we  deal  with  all  grades  of  defect,  from  an  equality  with  brutes  up  to  subnormality, 
hardly  removed  from  ourselves,  and  thereby  gain  a  number  of  steps  upon  what  the  com- 
parative anatomist  can  ever  take.  It  is  conceded  that  the  higher  mental  operations  have 
much  to  do  with  speech, —  its  storage  and  its  expression.  Now,  among  animals  few  traces 
of  speech  exist.  But  among  the  feeble-minded  all  degrees  of  speech  loss  may  in  the  course 
of  years  be  studied.  The  missing  links  and  intergrading  transitions  between  the  primates 
in  general  and  man  in  particular  may  be  found  in  feeble-mindedness.  By  proper  sifting  of 
cases,  future  investigation  will  discover  by  an  accumulation  of  instances  the  minimum 
mechanism  with  which  speech  can  be  effected. 

It  is  this  principle  of  the  minimum  apparatus,  the  minimum  machinery  with  which 
a  function  may  be  performed,  that  we  regard  as  the  most  important  and  promising 
aspect  of  feeble-mindedness  from  the  standpoint  of  research  into  mental  function.  As  we 
have  elsewhere  sketched,  fundamental  researches  in  the  psychology  of  efficiency  may  well 
be  made  with  the  feeble-minded,  since  among  them  we  shall  be  able  to  discover  what  can 
be  done  with  the  least  apparatus.     For  the  purpose  of  the  present  argument  we  need  not 


WAVERLEY   RESEARCHES.    III.  113 

develop  the  collateral  fact,  that  in  brain  disease  of  the  normal  adult  and  in  brain  disease 
of  epileptics  we  often  deal  with  far  more  complicated  problems  since  the  destruction  of  a 
few  bits  of  brain  apparatus  in  one  region  may  lead  to  functional  disuse  of  great  masses  of 
mechanisms  that  are  structurally  quite  intact.  Diaschisis  and  shock  are  instances  in 
point.  There  is  no  method  of  determining,  at  least  in  the  majority  of  nerve  cells,  whether 
they  are  performing  vegetative  or  conductive  functions,  or  no  functions  whatever.  Con- 
sequently the  principle  of  discovering  the  minimum  machinery  with  which  a  given  act 
may  be  performed  cannot  be  applied  as  a  rule  in  the  field  of  the  neuropathology  of  destruc- 
tive lesions. 

Mill's  method  of  study  by  means  of  concomitant  variations  is  a  method  much  more 
readily  applied  to  material  in  feeble-mindedness  than  to  the  ordinary  anatomo-clinical 
material  of  the  neurological  clinic. 

Now,  it  must  be  conceded  forthwith  that,  if  the  authorities  in  mental  tests  are  in  doubt 
as  to  their  ultimacy,  the  brain  anatomists  are  equally  modest  in  their  claims.  As  we  looked 
over  the  claims  of  the  workers  in  mental  tests,  we  concluded  that  these  mental  tests  could 
at  least  lay  claim  to  a  certain  orderliness,  such  that  a  patient  stated  to  have  a  mental  age,  of 
six,  was  at  all  events  of  less  mental  capacity  than  one  having  a  mental  age  of  seven  or  eight. 
In  short,  the  dicta  of  the  mental  tests  might  have  an  ordinal  value  if  they  did  not  possess 
cardinal  value.  Very  possibly,  also,  this  point  might  apply  to  the  point-scale  data  of  the 
Yerkes  tests,  although  this  perhaps  was  less  likely  on  account  of  the  fact  that  a  given  per- 
centage in  the  Yerkes  tests  might  be  made  up  of  exceedingly  heterogeneous  successes  in 
puzzle-solving,  the  doing  of  sums,  and  the  answering  of  questions.  Conceding  for  the 
moment  that  the  mental  tests  are  now  so  good  as  to  have  approximately  an  ordinal  value, 
such  that  a  patient  of  eight  years  mental  age  has  higher  intelligence  than  a  patient  having 
a  mental  age  of  seven  years,  we  can  see  that  it  might  be  well  to  compare  our  brains  of 
feeble-minded  subjects  together  so  that  we  might  learn  whether  here  also  there  was  an 
ordinal  value  to  attach  to  the  brains.  We  are,  doubtless,  far  from  the  achievement  of 
cardinal  values,  indicating  definite  increment  of  mental  capacity  to  correspond  with  definite 
increment  of  brain  mass,  even  should  our  studies  be  so  minute  as  to  permit  us  to  evaluate 
the  dendrite  supply  and  synaptic  surface  area  of  the  brain  cells  instead  of  their  mere  pro- 
portionate numbers.  But  might  we  not  be  able  to  arrange  our  brains  in  an  ordinal  series 
which  would  be  convincing  because  of  the  derivation  of  the  principles  of  arrangement  from 
a  number  of  sources:  say,  brain  weight,  proportionate  brain  weight  to  body  length,  com- 
plication of  sulci,  size  of  corpus  callosum,  etc.,  etc.? 

And  suppose  this  order  of  brains  to  be  obtained,  would  it  fit  at  all  with  the  order  of 
brains  obtainable  by  mental  tests?     If  the  two  series  were  largely  identical,  then  might 


114 


SOUTHARD   AND  TAFT. 


not  some  progress  be  thought  to  have  been  made  in  the  problem  of  the  relation  of  intelli- 
gence to  brain?  We  are,  of  course,  entirely  aware  that  this  principle  is  applicable  to  a 
large  series  only,  and  the  present  tables  are  offered  chiefly  to  lay  down  a  few  principles  as 
to  the  proper  lines  of  future  correlation  on  the  basis  of  more  cases.  We  have  placed  at  the 
head  of  Article  II  a  statistical  table  of  the  ten  cases  in  which  some  data  for  identification  are 
given.  In  the  following  table,  we  again  arrange  the  brains  in  their  order  of  acquisition  by 
the  laboratory.  In  separate  columns  we  place  the  age,  mental  age,  brain  weight  (whether 
less  or  more  than  average  according  to  our  view),  together  with  certain  anatomical  and 
histological  data. 

TABLE  II. 

Table  Displaying  Mainly  Histopathological  Findings,  Cases  I-X. 


Brain 

Focal 

Exudative 

Nerve 

Dislocated 

Weight 

Destructive 

Hydro- 

Lesion of 

Cell 

Fiber 

Satelli- 

Ganglion 

Numbei 

Age 

Mental  Age 

probably 

Lesion 

cephalus 

Rod  Cells 

Aplasia 

Loss 

Gliosis 

tosis 

Cells 

i 

5 

1-,  est. 

minus 

0 

moderate 

0 

marked 

marked 

slight 

0 

0 

ii 

20 

1-,  est. 

minus 

+ 

marked 

0 

marked 

marked 

marked, 
patchy 

+ 

0 

in 

45 

7,  est. 

minus 

0 

0 

0 

+ 

? 

+ 

+ 

0 

IV 

62 

moron  or 
subnormal 

plus 

0 

+ 

+ 

+ 

+ 

+ 

focal 

+ 

V 

16 

subnormal 

normal 

0 

slight 

0 

+ 

0 

+ 

0(d) 
focal 

+ 

VI 

26 

2,  est. 

minus 

0 

0 

+ 

rod  cells 

slight 

? 

+ 

+ 

0 

VII 

25 

5,  Binet 

normal 

thrombus 
(Hist.) 

0 

rod  cells 

slight 

? 

+ 

0 

0 

VIII 

36 

subnormal 

normal 

0 

0 

+ 

+ 

0 

+ 

+ 

+ 

IX 

39 

7,  Binet 

plus 

0 

0 

0 

+ 

0 

0 

0 

+,  slight 

X 

37 

24,  Binet 

plus 

0 

0 

? 

+ 

f 

+ 

+ 

0 

It  will  be  seen  that  one  case  (II)  is  apparently  the  result  of  a  focal  destructive  brain 
lesion  of  great  size.  This  case  was  probably  one  of  encephalitis, —  possibly  due  to  poli- 
omyelitis,—  and  yielded  a  marked  degree  of  hydrocephalus.  This  fact,  however,  did  not 
complicate  the  estimation  of  its  proper  place  in  the  anatomical  or  psychological  series, 
since  the  brain  was  clearly  upon  the  score  of  weight  and  simplicity  not  of  so  low  grade  as 
Case  I,  but  lower  than  any  other  brain.  Cases  I  and  II,  then,  appear  to  be  the  lowest 
brains  in  point  of  anatomy  and  the  lowest  cases  in  point  of  intelligence.  The  comparison 
may  be  made  even  finer,  since  beyond  question  the  brain  of  Case  I  was  the  least  complex 
of  the  entire  series,  and  the  mentality  of  this  case,  whose  actual  age  was  but  five  years,  was 
also  minimal. 

There  are,  however,  three  cases  of  pronounced  microcephaly,  namely;  cases  I,  II, 
and  III.     The  instance  of  Case  III  is  the  most  disquieting  in  the  analysis  so  far  from  the 


WAVERLEY    RESEARCHES.     III. 


115 


standpoint  of  aligning  the  brains  with  estimated  mental  capacity.  Case  III,  it  may  be 
remembered,  was  that  of  Little  Zip,  a  microcephalic,  who  lived  for  forty-five  years  a  vagrant 
life,  which  was  almost  self-supporting  in  the  hobo  sense  of  the  term.  With  the  brains 
superficially  suggestive  of  a  dog,  the  patient  himself  exhibited  a  number  of  doglike  features 
in  his  vagrant,  happy-go-lucky  life,  journeying  from  the  barn  or  house  of  one  friend  to  that 
of  another.  Arranging  the  brains  in  the  order  of  their  complexity,  the  brain  of  Little  Zip 
must  be  placed  third,  after  the  microcephalic  case  I  and  the  microhydrocephalic  case  (post- 
encephalitic) II,  and  yet  the  mental  age  of  Little  Zip  may  be  safely  estimated  as  about 
seven  years.  The  mental  age  is,  at  all  events,  much  higher  than  that  of  the  other  micro- 
cephalics. Thus,  if  the  brains  are  arranged  in  order  of  their  estimated  age,  the  brain  of 
Little  Zip  comes  in  sixth  or  seventh  place,  instead  of  in  the  third  place. 

Another  case  (IX)  may  be  chosen  as  well  illustrating  the  possibility  of  wrongly 
estimating  the  mental  capacity  of  a  patient  from  his  brain  appearances;  for  this  brain 
was  placed  upon  the  score  of  its  complexity,  largely  in  the  gross,  in  the  fifth  place.  Its 
mental  age  was  seven.  Yet  two  brains  that  are  regarded  as  still  more  complex,  namely; 
those  of  Cases  X  and  VII,  yielded  Binet  ages  of  2£  and  5  respectively.  The  microscopy 
of  Case  IX,  however,  should  that  be  taken  into  account,  would  insure  a  somewhat  lower 
place  for  the  brain  of  this  able-bodied  imbecile,  of  great  stature  and  large,  poorly-molded 
brain  (1620  grams;  more  than  200  grams  in  excess  of  an  estimated  norm).  The  examples 
of  Little  Zip  (Case  III)  and  of  the  able-bodied  imbecile  (Case  IX)  suffice  to  indicate  the 
difficulties  of  these  analyses. 

The  following  table  (Table  III)  shows  the  brains  arranged  in  the  order  of  their  estimated 
complexity,  and  the  figures  in  the  intelligence  column  will  readily  demonstrate  the  facts 
just  mentioned,  concerning  the  dislocation  of  cases  III  and  IX  from  their  proper  places  in 
the  series  if  we  estimated  the  brains  on  their  gross  complexity  alone. 

TABLE  III. 

Comparison  of  Brain  Complexity,  Brain  Weight,  and  Order  of  Intelligence  in  Cases  I-X. 


Brain 

Brain 

Number 

Age 

Complexity 

Weight 

Intelligence 

i 

5 

a) 

400-,  est. 

1-,  est. 

ii 

20 

b) 

620 

1-,  est. 

in 

45 

c) 

610 

7,  est. 

VI 

26 

d) 

1130 

2,  est. 

IX 

39 

e) 

1620 

7,  Binet 

X 

37 

f)  or 

g) 

1450 

2.4,  Binet 

VII 

25 

f)  or 

g) 

1270 

5,  Binet 

IV 

62 

h) 

1340 

Moron  or  subnormal 

v 

16 

i)  or 

i) 

1435 

Subnormal 

VIII 

36 

i)  or 

i) 

1340 

Subnormal 

116 


SOUTHARD   AND  TAFT. 


Table  IV  arranges  the  brains  in  the  order  of  actual  brain  weight,  but  gives  also  the 
brain  weights  estimated  by  Tigges's  formula  (eight  times  the  body  length  in  centimeters  = 
brain  weight  in  grams).  The  brain  weight  for  the  normal  age  and  sex  of  the  individual 
taken  from  Vierordt's  tables  is  also  given. 


TABLE  IV. 

Comparison  of  Brain  Weight,  Corrected  Brain  Weights,  and  Order  of  Intelligence  in  Cases  I-X. 

(Arranged  in  order  of  actual  brain  weight). 


Number, 

Age, 

Brain  Weight 

Brain  Weight 

Brain  Weight 

Height  (cm.) 

Tigges 

Age   normal  (Sex) 

Actual 

Intelligence 

I,     5,  81 

648 

1282, 

M 

400-,  est. 

1-,  est. 

III,  45,  126 

1008 

1348-66, 

M 

610 

7,  est. 

II,  20,  subn. 

? 

1358-96, 

M 

620 

1-,  est. 

VI,  26,  158 

1264 

1358-96, 

M 

1130 

2,  est. 

VII,  25,  146 

1168 

1234-39, 

F 

1270 

5,  Binet 

IV,  62,  141 

1128 

1178-1210 

,F 

1340 

Moron  or  subnormal 

VIII,  36,  179 

1432 

1365-6, 

M 

1340 

Subnormal 

V,  16,  168 

1344 

1358-96, 

M 

1435 

Subnormal 

X,  37,  144 

1152 

1365-6, 

M 

1450 

2.4,  Binet 

IX,  39,  178 

1424 

1365-6, 

M 

1620 

7,  Binet 

Table  V  presents  the  cases  in  the  order  of  their  estimated  intelligence. 


TABLE  v. 


Comparison  of  Order  of  Intelligence  with  Complexity  of  Brain  in  Cases  I-X. 


Brain 

Number 

Actual  Age 

Intelligence 

Complexity 

Remarks 

i 

5 

1-,  est. 

a) 

ii 

20 

1-,  est. 

b) 

VI 

26 

2,    est. 

d) 

Vocal  cord  absent 

X 

37 

2.4,  Binet 

f)  or  g) 

VII 

25 

5,  Binet 

f)  or  g) 

IX 

39 

7,  Binet 

e) 

Out  of  place 

III 

45 

7,  est. 

c) 

"Zip,"  out  of  place! 

IV 

62 

Moron  or  subnormal 

h) 

Almshouse  transfer 

V 

16 

Subnormal 

i)  or  j) 

Dementia  praecox 

VIII 

36 

Subnormal 

i)  or  j) 

Murderer 

It  seems  safe  to  conclude  from  these  tables  that  at  least  the  brains  of  least  complexity 
are  correlated  with  the  minds  of  least  range,  and  that  the  brains  of  greater  complexity  are 
in  a  general  way  correlated  with  minds  of  greater  range.  By  microscopic  correction  of 
the  anatomical  decisions,  we  may  even  cause  our  figures  to  look  still  more  satisfactory 
from  the  standpoint  of  identical  ordering  of  anatomical  and  psychological  data.     Whether 


WAVERLEY   RESEARCHES.    III.  117 

the  future  may  show  how  to  account  for  the  apparent  too-great  simplicity  of  the  brain  of 
Little  Zip,  remains  to  be  seen. 

The  second  point  in  our  epicritical  review  may  be  presented  briefly,  partly  on  the  basis 
of  Table  II,  in  which  the  findings  of  exudative  lesion  or  rod  cells  are  entered,  and  also  by 
means  of  Table  VI,  in  which  are  displayed  the  majority  of  the  anatomical  findings  in  the 
series.  How  many  of  our  cases  may  be  regarded  as  essentially  preventable  by  the  means 
theoretically  available  to  the  mental  or  psychiatric  hygiene  of  the  individual,  leaving  out, 
that  is  to  say,  the  eugenic  line  of  attack?  Let  us,  perhaps,  grant  that  Case  II,  with  its 
focal  destructive  lesion, —  possibly  of  postencephalitic  origin, —  its  marked  hydrocephalus, 
marked  nerve  cell  and  fibre  loss,  and  marked  patchy  gliosis,  with  its  focal  microgyria  in 
other  regions  than  the  most  marked  post-encephalitic  lesion,  is  a  case  that  is  preventable, — 
that  is  by  social  and  scientific  devices  which  shall  exclude  this  presumably  infectious 
disease  from  occurring. 

If  we  take  at  their  face  value  the  slight  mononucleosis  of  cases  IV,  VI,  VIII,  and  X, 
we  may  perhaps  consider  them  as  either  syphilitic  or  as  suffering  from  progressive  exudative 
disease  of  a  mild  nature,  also  theoretically  preventable.  Now,  in  point  of  fact,  we  are  far 
from  proving  that  these  four  cases  are  cases  of  syphilis;  or  that  Case  VII,  a  case  which  fails 
to  demonstrate  lymphocytosis  but  does  demonstrate  rod  cells,  is  a  case  of  syphilis.  It  is, 
however,  of  importance  to  consider  that  in  a  series  of  ten  cases  of  numerous  grades  of  feeble- 
mindedness, no  less  than  six  show  processes  of  a  suspiciously  progressive  nature  or  suggestive 
of  infection.  Here  is  a  problem  that  is  well  worth  working  out  in  the  utmost  detail,  whether 
we  lay  down  the  problem  as  a  problem  of  the  frequency  and  distribution  of  syphilis  in  the 
feeble-minded,  or  whether  we  seek  to  establish  the  part  played  in  feeble-mindedness  by 
acquired  disease. 

Let  us  sum  up  these  considerations  by  saying  that  the  number  of  cases  in  which  the 
hypothesis  of  infection  must  be  more  or  less  firmly  entertained  is  much  larger  than  has  been 
supposed.  By  consequence,  the  scales  tip  much  farther  for  the  group  of  the  so-called 
secondary  amentias  than  was  the  supposition  with  most  workers. 

In  addition  to  these  main  points  in  our  epicritical  review,  namely;  the  point  concerning 
the  relation  of  the  complexity  of  brain  to  capacity  of  mind,  and  the  point  concerning  the 
theoretical  preventability  of  certain  cases,  we  should  not  dismiss  our  review  without 
slightly  indicating  the  richness  of  the  field  in  points  of  interest  to  neurology.  The  teratolo- 
gist  and  embryologist  are  sufficiently  aware  of  these  values,  so  that  we  need  not  make 
special  point  of  the  Affenspalte  question  (for  instance,  Case  I  and  Case  III) ;  the  question  of 
cruciate  asymmetry  (Case  V),  the  question  of  the  absence  of  the  middle  commissure  (Cases 
V,  VII,  IX,  and  X) ,  the  question  of  presence  of  dislocated  ganglion  cells  in  the  white  matter 


118 


SOUTHARD   AND   TAFT. 
TABLE   VI. 


Case 
Num- 
ber 

Calvarium 

Dura  Mater 

Pia  Mater 

Vessels 

Brain 
Weight 
Grams 

Gyri 

Diffuse 
Atrophy 
or  Aplasia 

Focal 
Atrophy 
or  Aplasia 

Corpus 
Callosum 

I 

slight  general 
thickening 

negative 

400,  est. 

Microcephaly 

marked 

variations; 
"affenspalte" 
left 

proportionate 

II 

thick  frontal ; 
depressions 

normal 

normal 

negative 

620 

Microcephaly 

marked 

microgyria, 
2nd  frontal, 
etc. 

thin 

III 

moderately 

normal 

normal 

negative; 

except 

vertebrals 

610 

Microcephaly 

marked 

minor  anom- 
alies 

proportionate 

IV 

dense 

slight  thick, 
frontal 

slight  thick, 
vertex 

negative 

1340 

Focal  micro- 
gyria and 
asymmetry 

no 

minor  anom- 
alies 

rather  thin 

V 

negative 

negative 

slight  general 
clouding  ver- 
tex 

negative 

1435 

Cruciate 
asymmetry 

absent 

frontal;  oper- 
cular 

slightly  thin, 
posterior  third 

VI 

inequalities  of 

thickness, 

brittle 

thick  along 

middle 

meningeals 

slight  general 
thickening 

negative 

1130 

simple,  sym- 
metrical 

absent 

Frontal 

thin  through- 
out 

VII 

dense 

adherent  at 
corono-sag- 
ittal  suture 
line 

faintly  hazy, 
vertex  and 
sulci 

negative 

1270 

slight  asym- 
metry; simple 
construction 

absent 

Frontal 

thin,  horizon- 
tal portion 

VIII 

thickened 

negative 

1340 

slight  asym- 
metry; trans- 
verse gyri 

absent 

left  parietal 

moderate  thin- 
ing,  posterior 
third 

IX 

thick,  some- 
what dense 

thick 

focal  basal 
leptomeningi- 
tis 

negative 

1620 

slight  asym- 
metry; "poor- 
ly moulded  " 

absent 

absent 

narrow,    poste- 
rior third 

X 

dense 

focal  thick- 
ening 

cerebellar  pia 
thickened; 
pia  in  general 
thick 

negative 

1450 

slight  asym- 
metry 

general 
superficial 

Frontal 

slight  thinning, 
posterior  third 

WAVERLEY  RESEARCHES.   III. 
TABLE  VI  (continued). 


119 


Middle 
Commissure 


Consistence 


Sclerotic  Foci 


Other 
Foci  Destructive 


Ventricles 

Hydro- 
cephalus 


Cerebellum       Spinal  Cord 


Remarks 


absent 


absent 


absent 


present 


absent 


absent 


not  remarkable 


not  remarkable 


not  remarkable 


normal 


normal  in  general 


normal 


normal;  putty- 
like at  base 


unusually  firm; 
"  brain  swelling ' 


absent 


absent 


absent 


left  2nd  tem- 
poral firm,  yel- 
low 

absent 


absent 


absent 


absent 


left  parietal 


absent 


absent 


acquired?  slight 
lesion,  left  callo- 
so-marginal 

absent 


canalized 
thrombus 
(histologically) 


absent 


absent 


absent 


moderate 


marked 


present 


slight 


0? 


negative 


negative 


inferior 
vermis  ab- 
sent? 

dentate 

nuclei 

unequal 

negative 


negative 


negative 


negative 


negative 


small 


negative 


negative 


early  focal  encephalitis, 
(poliomyelitic?) 


mononucleosis,    posterior 
septum,  spinal  cord 


negative 


negative 


negative 


rod  cells;    lymphocytes   in 
smear,  frontal 


rod  cells 


plasmocytosis,  focal,  left 
prefrontal 


negative 


?mononucleosis,  focal,  right 
postcentral  (dead  of  pel- 
lagra; tuberculous) 


120  SOUTHARD  AND  TAFT. 

(Cases  IV  and  V,  and  to  a  slight  degree,  Case  IX),  the  problem  of  the  time  relations  of 
satellitosis  (as  shown  in  cases  II,  III,  VI,  VIII,  and  X;  and  focally,  in  IV  and  V),  and  the 
question  of  defective  cortex  lamina  (as  shown  characteristically  in  Case  IX).  We  choose 
for  exposition  a  somewhat  more  recondite  point,  namely;  the  significance  of  hydrocephalus 
in  some  of  these  cases. 

The  significance  of  hydrocephalus  in  Cases  I  and  II  with  microcephalic  brains  is  hard 
to  judge.  Whether  the  microcephaly  is  due  to  hypoplasia  or  to  agenesia,  it  would  naturally 
not  be  unlikely  that  there  should  be  an  absence  of  neurones,  both  on  the  exterior  and  in  the 
interior,  or  both  in  the  outer  and  inner  portions  of  the  brain  substance.  Accordingly 
the  hydrocephalus  exhibited  in  the  brains  of  Cases  I  and  II  is  not  necessarily  to  be  associated 
with  increase  of  intracranial  pressure  at  any  time  in  the  lives  of  the  patients.  The  hydro- 
cephalus in  Case  II  is  very  possibly  to  be  related  with  an  early  focal  acquired  lesion  of  the 
nervous  system  (paralytic  shock  stated  to  have  occurred  at  three  months  of  age  by  attending 
physician).  The  hydrocephalus  in  Case  III  is  possibly  to  be  explained  similarly,  and  does 
not  require  the  hypothesis  of  heightened  intracranial  pressure  at  any  time  in  the  life  of  the 
patient. 

Aside  from  hydrocephalus  associated  with  microcephaly,  and  possibly  due  to  the 
operation  of  identical  causes,  we  must  consider  on  another  basis  the  hydrocephalus  of  four 
other  cases:   IV,  V,  VII,  and  X. 

The  hydrocephalus  of  Case  IV  is  voluminous  and  is  associated  with  a  corpus  callosum 
rather  thinner  than  normal,  and  in  fact  very  thin  posteriorly  opposite  the  region  of  greatest 
ventricular  dilatation.  The  motor  restlessness  of  this  case  may  or  may  not  be  correlated 
with  the  ventricular  dilatation,  as  has  been  contended  by  Southard  in  his  work  on  dementia 
praecox  in  1915,  and  in  a  later  analysis  of  hydrocephalus  in  the  so-called  functional  psy- 
choses, as  yet  unpublished.  However,  it  may  well  seem  to  the  anatomist  that  the  hydro- 
cephalus would  best  be  regarded  as  one  due  to  tissue  atrophy  of  a  gradual  nature,  not  in 
any  wise  necessarily  related  to  alterations  of  intracranial  pressure.  The  external  features 
of  the  brain  do  not  show  recent  effects  of  ventricular  swelling.  Accordingly,  we  should 
not  lay  particular  stress  on  the  occurrence  of  ventricular  dilatation  associated  with  motor 
restlessness  in  Case  IV. 

Case  V  shows  dilatation  of  the  right  lateral  ventricle  without  dilatation  of  the  left 
(in  fact,  there  may  have  been  a  slight  degree  of  internal  brain  swelling  which  has  caused  the 
surfaces  of  the  left  ventricle  to  come  into  apposition).  This  finding  of  unilateral  hydro- 
cephalus has  not  been  infrequent  in  Southard's  dementia  praecox  series  of  1915;  has  been 
there  referred  to  at  length,  and  also  in  the  later,  as  yet  unpublished,  analysis.  In  cases 
VII  and  X,  we  are  dealing  neither  with  pronounced  microcephaly  (the  brain  weights 


WAVEKLET   RESEARCHES.    III.  121 

respectively  are  1270  and  1450  grams,  accordingly  over  weight  according  to  Tigges'  formula 
of  brain  weight  in  grams  equal  to  eight  times  the  body  length  in  centimeters) ,  nor  with  the 
special  conditions  of  a  possibly  atrophic  brain  in  an  imbecile  of  62  years,  Case  IV,  and  the 
special  features  of  the  case  of  dementia  praecox,  Case  V.  Cases  VII  and  X,  curiously 
enough  from  our  present  standpoint,  are  examples  of  such  an  imbecile  as  is  rather  apt  to  be 
termed  by  the  laymen  insane,  or  "crazy",  imbecile.  The  point  of  the  attendant's  or 
layman's  remark  is  not  that  such  an  imbecile  belongs  in  the  group  of  the  psychoses  as  the 
physician  views  them,  but  that  the  patient  is  insane  or  "crazy"  from  the  nonmedical 
standpoint;  showing  spells  of  marked  irritability.  Thus,  Case  VII  is  described  as  having 
had  tantrums,  as  being  "hysterical"  on  examination,  laughing  one  minute  and  crying  the 
next,  rushing  about,  jumping  up  and  down,  and  screaming  on  occasion,  and  was  regarded 
as  a  very  troublesome  case. 

Case  X  is  described  as  having  been  somewhat  feeble  on  admission  to  the  school  at  the 
age  of  10  years,  but  as  later  becoming  very  troublesome,  with  quick  temper  and  noisiness. 

This  problem  of  the  relation  of  hydrocephalus  to  hyperkinesis,  as  first  developed 
from  Southard's  dementia  praecox  work  of  1915,  can  hardly  be  settled  in  its  relation  to 
feeble-mindedness  from  this  series,  for  if  we  exclude  the  three  markedly  microcephalic 
cases  (Cases  I,  II,  and  III),  the  old  demented  imbecile  (Case  IV),  the  case  of  dementia 
praecox  (CaseV),  and  the  executed  murderer  (Case  VIII),  we  are  left  with  but  four  cases: 
VI,  VII,  IX,  and  X,  of  which  VII  and  X  were  hydrocephalic  and  had  been  as  sketched 
above  as  to  their  tendencies  to  over-activity.  If  we  consider  in  contrast  to  these  VI  and 
IX,  (the  cases  we  have  termed  "typical  idiot"  and  "peculiar  imbecile"  with  some  capacities 
above  the  imbecile  grade),  we  find  ourselves  dealing  with  brains  of  simple  construction 
and  of  poor  moulding  respectively,  in  which  brains  there  is  no  evidence  of  hydrocephalus 
despite  the  fact  that  the  brains  show  the  corpus  callosum  in  both  instances  to  be  thinned 
out  posteriorly.  (In  fact,  the  corpus  callosum  of  Case  VI  is  everywhere  rather  thinner 
than  usual.)  Case  VI  was  a  very  restless  and  nervous  idiot,  described  as  "always  looking 
around,"  and  as  "inclined  to  be  destructive".  It  appears  that  these  tendencies  were 
constant  and  not  more  marked  at  one  time  than  another.  The  case  seemed  to  be  one  of 
slight  microcephaly  (brain  weight,  1130,  is  134  grams  under  Tigges'  formula  for  the  patient's 
height,  158  cm.).  "Constant  nervousness"  or  hyperkinesis  can  hardly  be  supposed  to  be 
associated  with  hydrocephalus  except  accidentally  and  independently  of  any  casual  inter- 
relation. The  point  of  the  coexistence  of  overactivity  and  hydrocephalus  in  the  micro- 
cephalic would  lodge  rather  in  the  simplicity  of  the  neuronic  system  in  the  microcephalic 
case.  It  is  clear  that,  if  the  microcephalic  brain  is  also  hydrocephalic,  the  neuronic  systems 
of  the  brain  in  question  must  be  still  simpler  in  make-up.     If  the  brain  in  question  is 


122  SOUTHARD   AND  TAFT. 

taking  in  anything  like  the  normal  number  of  ingoing  stimuli,  and  the  capacity  of  the 
brain  to  dampen  or  inhibit  the  stimuli  and  divert  them  from  taking  effect  in  motion,  is 
a  diminishing  capacity,  then  over-activity  becomes  the  most  natural  result  of  the  simplicity 
of  the  brain  and  one  quite  to  be  expected. 

Accordingly,  although  the  typical  idiot  ( Case  VI)  yielded  a  brain  without  hydrocephalus 
and  yet  was  over-active,  it  is  clear  that  the  over-activity  is  not  of  the  type  of  the  occasional 
hysterical  outburst;  thus,  whereas  Cases  VII  and  X  are  described  as  excitable,  Case  VI 
would  best  be  described  as  restless  or  "nervous". 

Case  IX  showed  no  restlessness  or  excitability  at  any  time,  having  a  good  disposition 
and  in  general  a  rather  cooperative  nature. 

Our  problem,  accordingly,  as  based  on  the  analysis  of  this  group  of  cases  from  the 
standpoint  of  hydrocephalus,  may  be  summed  up  as  follows : 

The  association  of  internal  hydrocephalus  with  microcephaly  may  well  be  incident 
to  the  mal-development,  that  is  to  say,  merely  a  part  of  the  result  of  the  factors  which  have 
retarded  or  stopped  the  growth  of  the  brain.  Accordingly,  under  these  circumstances, 
alterations  of  intracranial  pressure  are  neither  necessary  nor  in  fact  very  likely  to  occur. 
Moreover,  dilatation  of  the  ventricles  in  old  age  and  in  dementia  praecox  must  be  considered 
separately.  If  there  is  any  relation  between  occasional  outbursts  of  excitability  and  altera- 
tions of  intracranial  pressure  which  have  to  do  with  the  production  of  hydrocephalus, 
many  more  cases  will  be  necessary  to  make  the  point  certain.  We  have  one  good  instance 
to  show  that  constant  restlessness  is  not  necessarily  associated  with  hydrocephalus.  A 
further  physiological  and  psychological  analysis  of  the  difference  between  excitability 
and  restlessness  would  be  very  desirable,  both  for  its  intrinsic  interest  and  for  the  light  it 
may  throw  upon  these  structural  conditions,  which  are  difficult,  if  not  impossible  to  interpret 
when  considered  entirely  by  themselves. 


Summary. 

The  entirely  provisional  conclusions  of  the  epicritical  review  may  be  briefly  stated  as 
follows : 

First,  it  is  not  impossible  that  the  problem  of  matching  brain  complexity  with  mental 
capacity  may  be  solved  by  a  much  larger  series  of  instances  than  is  here  available;  but 
the  instances  of  such  matching  as  has  been  undertaken  are  somewhat  convincing  as  to  the 
correlations  of  low  orders  of  intelligence  with  simple  brains  and  of  higher  orders  of  intelli- 
gence with  more  complex  brains.     Occasional  exceptions  to  the  rule  may  be  explained  by 


WAVERLEY   RESEARCHES.    III.  123 

the  finer  anatomy  of  certain  cases  (Case  IX) ;  others  remain  less  easy  to  explain  away  (Case 
III). 

Secondly,  the  partial  orienting  and  microscopic  examination  yielded  more  instances 
of  slight  exudative  lesions  (including  in  some  instances  rod  cells)  than  might  have  been  d 
priori  expected  from  a  relatively  stable  institutional  material  like  that  here  largely  drawn 
upon.  What  the  share  of  syphilis  in  this  group  of  cases  may  really  be  is  doubtful.  There 
was  one  instance  of  feeble-mindedness  very  possibly  due  to  an  early  focal  encephalitis  en- 
tailing mal-development  of  brain. 

Thirdly,  as  an  example  of  special  neurological  interest  attaching  to  this  study,  some 
considerations  about  hydrocephalus  offered  bring  up  the  question  of  the  relation  between 
occasional  bursts  of  excitability  and  alterations  of  intracranial  pressure  with  the  production 
of  hydrocephalus. 


124  southard  and  taft. 

Description  of  Photographs. 
Views  of  Case  I. 

The  gross  photographs  of  the  stripped  brain  alone  are  presented  since,  although  there 
was  a  slight  general  thickening  of  the  pia  mater,  the  microscopy  of  the  tissue  has  so  far 
shown  no  evidence  of  exudate. 

Note  in  photographs  I-a,  I-c,  and  I-d  the  striking  projection  of  the  cerebellum  behind 
the  occipital  poles.     Note  the  suggestion  of  Affenspalte  (I-a). 

Note  in  I-b  the  large  exposure  of  the  crura  cerebri,  as  well  as  the  comparatively  small 
number  of  transverse  pontine  fibres  arranged  in  almost  distinct  bundles.  Note,  also, 
in  I-b  the  comparative  size  of  the  optic  tracts  and  olivary  eminences. 

Note  in  I-a,  I-c,  and  I-d  the  bi-convolute  construction  of  the  frontal  lobe;  the  su- 
perior frontal  convolution,  broader  than  the  inferior,  may  represent  superior  and  middle 
frontal  convolutions  of  more  highly  developed  brains.  Note  the  excellent  development  of 
the  pyrif orm  lobule  on  each  side,  especially  the  right  (I-b) . 

We  present  in  I-e,  I-f,  and  I-g,  three  views  of  the  brain  in  total  section  as  stained 
by  the  Weigert  myelin  sheath  method.  (Note  that  the  stains  are  relatively  successful 
despite  the  preservation  of  the  brain  for  eleven  years  in  formaldehyde  solution.)  A  moderate 
degree  of  hydrocephalus  is  notable  in  I-f.  The  small  size  of  the  leaflets  of  the  cerebellum 
is  to  be  noted  in  I-g.  The  comparatively  greater  depth  of  the  sulci  than  those  found 
in  more  normal  brains  is  obvious  in  each  of  the  total  brain  section  views. 

This  case  is  thought  to  have  possessed  the  lowest  mental  age  in  the  entire  series.  An 
older  sister  of  the  patient  was  almost  equally  defective  and  almost  identically  micro- 
cephalic; other  children,  before  and  after,  were  not  microcephalic. 

Views  of  Case  II. 

The  gross  photographs  of  the  stripped  brain  alone  are  presented  since  the  membranes 
were  normal  and  there  were  no  microscopic  evidences  of  exudative  disease. 

Photograph  Il-a  demonstrates  the  focal  posterior-lying  areas,  especially  marked 
on  the  left  side  with  microgyria.  This  case  of  microcephaly  exhibits  a  higher  degree  of 
hydrocephalus  than  did  Case  I,  as  is  demonstrable  from  the  total  brain  sections  II— f, 
Il-g,  and  Il-h.  Il-a  also  shows  frontal  depressions  corresponding  with  depressions  in  the 
skull.  Note  in  Il-a,  II-c,  and  Il-d  the  distinct  projection  of  the  cerebellum  behind  the 
occipital  poles;  a  projection  less  marked  than  in  Case  I. 


WAVERLEY   RESEARCHES.    III. 


125 


Note  in  II-c  an  area  of  microgyria  in  the  second  frontal  gyrus;  a  similar  area  is  less 
marked  in  Il-d.  Il-a  demonstrates  that  the  area  of  microgyria  begins  almost  abruptly 
with  the  postcentral  gyrus;  whereas  the  precentral  gyrus  on  each  side  is  of  fair  width  and 
well  rounded.  Photographs  II-c  and  Il-d  demonstrate  that  the  microgyria  is  far  less 
marked  on  the  flanks  and  inferiorly  than  superiorly;  and  this  contrast  is  strongly  brought 
out  in  the  total  brain  section  view,  Il-g  and  Il-h. 

The  mental  age  of  this  case  was,  also,  one  year  or  less,  but  the  intelligence  of  the  patient 
was  greater  than  that  of  Case  I.  Clinical  observation  of  the  patient's  general  behavior 
indicated  that  he  was  in  the  habit  of  attending  to  bright  colors,  looking  at  pictures, 
watching  boys  at  play,  and  taking  interest  in  events  about  him.  The  question  arises, 
whether  these  functions  are  largely  related  so  far  as  they  are  of  visual  origin  with  the 
inferior  rather  than  the  superior  tissues  of  the  occipital  lobe.  It  may  be  noted  that  the 
Weigert  myelin  sheath  stains  are  relatively  successful  with  this  brain  although  it  was 
preserved  in  formaldehyde  for  13  years. 


Views  of  Case  III. 

The  views  of  this  case  are,  also,  limited  to  the  stripped  brain  for  the  same  reasons 
as  in  Cases  I  and  II.  Note  the  general  symmetry  of  this  brain.  The  views  do  not  include 
the  cerebellum,  which,  however,  did  not  project  beyond  the  plane  of  the  occipital  poles. 
Note  in  Ill-a  the  suggestion  of  Affenspalte  on  the  right  side. 

Note  that  the  gyri  are  everywhere  narrow  and  simple  in  arrangement,  and  that  the 
secondary  sulci  are  rarely  complicated  by  collaterals.  A  special  description  in  the  text 
is  made  of  the  parietal  regions,  which  in  Ill-a  are  quite  unlike. 

III-c  and  Ill-d  show  at  the  base  of  the  frontal  gyri,  separating  them  from  the 
precentral  convolutions,  short,  deep,  transverse  sulci,  somewhat  suggesting  the  sulcus 
cruciatus  of  the  brain  of  a  dog.  Note,  in  fact,  the  somewhat  general  superficial  resemblance 
of  the  brain  of  this  case  to  that  of  a  dog. 


Views  of  Case  IV. 

Views  IV-a  and  IV-b  are  presented  of  the  unstripped  brain  viewed  from  above  and 
below,  partly  because  there  is  a  slight  thickening  of  the  pia  mater  at  the  vertex,  and  partly 
because  microscopic  examination  showed  a  mononucleosis  of  the  posterior  septum  of  the 
spinal  cord,  which  naturally  gives  rise  to  the  suspicion  of  former  syphilis,  although  it 


126  SOUTHARD  AND  TAFT. 

fails  to  prove  the  existence  of  syphilis.  IV-c  and  IV-d  show  the  same  aspects  with  the 
pia  mater  stripped. 

IV-c,  IV-e,  IV-f  show  a  lack  of  division  of  the  primary  sulci  of  the  frontal  lobe  on 
account  of  the  interruption  of  annectants.  The  parietal  convolutions  are  also  narrow: 
IV-c,  IV-e,  IV-f. 

IV-d  shows  a  right  pyriform  lobule  larger  and  more  prominent  than  the  left.  Now, 
the  left  side  of  the  brain  in  general  appears  slightly  more  hypoplastic  (or  atrophic?)  than 
the  right,  so  that  Case  IV  exhibits  a  diminution  of  the  crossed  and  uncrossed  systems  on  the 
same  side  of  the  brain.  (We  here  proceed  upon  the  basis  that  the  connections  of  the  left 
pyriform  lobule  are  largely  with  the  left  olfactory  zone,  whereas  the  connections  of  the 
neopalium  are  largely  crossed.)  Compare,  accordingly,  the  cruciate  asymmetry  which 
appears  in  Case  V.  We  might  argue  that  the  conditions  in  Case  IV  are  of  more  recent 
origin  than  those  of  Case  V.  At  least,  if  we  desire  to  attribute  the  cruciate  asymmetry 
of  Case  V  to  the  operation  of  a  single  agent  at  or  before  the  beginning  of  decussation,  of 
course  this  case, —  the  oldest  in  the  series, —  was  microscopically  found  subject  to  gliosis, 
and  the  whole  brain  shows  a  tendency  to  atrophy  with  slightly  flaring  sulci.  It  may  be 
that  the  condition  is  one  of  atrophy  and  not  of  aplasia,  and  that  the  atrophy  has  little  or 
nothing  to  do  with  the  feeble-mindedness  of  the  case. 

The  gross  sections  are  presented  with  some  completeness  (four  views,  IV-g  to  IV-j) 
for  the  reason  of  the  somewhat  surprising  degree  of  hydrocephalus  which  the  external 
views  would  hardly  give  one  cause  for  suspecting. 

The  best  argument  for  feeble-mindedness  in  this  case  is  microscopic,  namely;  the 
presence  of  dislocated  ganglion  cells  in  the  white  matter. 


Views  of  Case  V. 

The  unstripped  views  of  Case  V  are  omitted,  as  in  several  previous  cases,  because  of 
the  lack  of  acute  or  progressive  exudative  process. 

V-a  presents  the  not  unusual  frontal  and  occipital  cruciate  asymmetry.  In  this 
instance,  the  loft  frontal  and  left  occipital  lobes  are  smaller  than  their  fellows.  The  mesial 
views  V-g  and  V-h  show  a  slight  amount  of  thinning  out  in  the  posterior  third  of  the  corpus 
callosum. 

As  in  Case  IV,  the  best  argument  for  feeble-mindedness  in  this  case  is  microscopic, 
namely;  the  presence  of  dislocated  ganglion  cells  in  the  white  matter.  Naturally,  this 
argument  may  not  be  convincing.     In  general,  the  gross  findings  in  the  case  resemble 


WAVERLEY   RESEARCHES.    III.  127 

those  of  dementia  praecox  in  their  mildness  and  unilaterality.     These  appearances  are 
borne  out  in  a  cross  section  (V-d). 

Views  of  Case  VI. 

Unstripped  appearances  from  above  and  below  are  'presented  in  Vl-a  and  Vl-b, 
because  there  was  not  only  a  general  thickening  of  slight  degree  of  the  pia  mater,  but 
lymphocytes  were  found  in  a  smear  from  the  frontal  region  as  well  as  a  few  rod  cells  in 
certain  areas.  These  appearances  may  well  suggest  syphilis.  But  one  focus  of  perivascular 
lymphocytosis  has  been  found  in  the  microscopic  study,  which  was  in  this  instance  chiefly 
limited  to  the  stripped  brain.  Despite  the  indication  of  syphilis,  this  case  was  a  rather 
typical  instance  of  a  "grinning  idiot",  who  was  perhaps  classed  too  low  under  the  Binet 
test  because  of  his  aphasia,  which  aphasia  may  have  been  in  part  due  to  the  absence  of  one 
vocal  cord.  There  were  certain  other  suspicions  of  syphilis  in  the  case.  The  corpus 
callosum  was  thin  throughout  (see  especially  Vl-g  and  Vl-h). 

Views  of  Case  VII. 

The  unstripped  appearances  in  Case  VII,  viewed  from  above  and  from  below,  are 
likewise  shown,  although  the  pia  mater  was  but  faintly  hazy  throughout.  The  microscopic 
examination,  however,  demonstrated  rod  cells,  from  which  may  perhaps  be  suspected  a 
more  progressive  condition  than  is  assumed  to  be  typical  of  feeble-mindedness.  The 
mental  age  of  this  case,  though  set  at  five,  seemed  too  high  in  a  number  of  respects.  The 
case  also  showed  some  sensory  disorder.  As  in  Case  VI,  there  was  apparently  a  suspicion 
of  syphilis. 

The  views  of  the  stripped  brain  exhibit  a  fairly  complex  construction.  The  cross 
sections,  Vll-g  and  Vll-h,  show  a  narrow  corpus  callosum. 

Views  of  Case  VIII. 

On  account  of  the  focal  plasmocytosis  of  the  left  prefrontal  area,  the  unstripped  views 
of  the  vertex  (VHI-a),  the  left  flank  (VHI-b),  and  the  left  mesial  surface  (VIII-c)  are 
presented.  There  was  no  suspicion  of  syphilis  in  this  case  clinically,  and  it  may  be  that 
the  condition  found  is  due  to  some  other  intercurrent  condition,  which  may  possibly  have 
set  in  even  after  the  crime  for  which  the  patient  was  executed.  The  stripped  appearances 
show  a  number  of  transversely  directed  gyri  and  a  failure  to  approximate  on  the  part  of  the 
summits  of  numerous  gyri.     This  is  especially  shown  in  the  view  of  the  left  flank  (VHI-b). 


128 


WAVERLEY   RESEARCHES.    III. 


Perhaps  the  strongest  argument  for  feeble-mindedness  in  the  case  is  the  dislocated 
ganglion  cells  in  the  white  matter  of  certain  areas  (very  few).  The  narrowing  of  the 
posterior  third  of  the  corpus  callosum  is  best  shown  in  the  mesial  views  VIII-c,  VHI-e; 
less  well  in  VHI-f,  VHI-g,  VHI-h,  and  VHI-i. 

Views  of  Case  IX. 

The  unstripped  appearances  in  Case  IX  are  presented  from  above  and  below  (IX-a 
and  IX-b)  and  mesially  (IX-c  and  IX-d)  to  exhibit  a  focal  leptomeningitis,  especially 
at  the  base.     But  there  was  no  evidence  of  acute  or  chronic  inflammation  microscopically. 

The  stripped  appearances  (IX-e  to  IX-j)  show  slight  asymmetry  and  a  brain  in  general 
of  great  size  but  poor  molding.  The  mesial  views  (IX-i  and  IX-j)  show  a  narrowing  of 
the  posterior  third  of  the  corpus  callosum. 

Views  of  the  brain  in  cross  section  are  shown  with  comparative  fulness  on  account  of 
the  irregularity  in  the  distribution  of  hypoplasia  as  suggested  by  the  microscopic  examina- 
tion. Especially  the  right  superior  frontal  region  (IX-k)  exhibited  the  most  marked 
architectural  disturbance  microscopically.  A  cyst-like  area  in  the  right  hemisphere  of 
IX-1  is  due  to  artifact. 

Views  of  Case  X. 

Photograph  X-a  illustrates  the  unstripped  appearances,  to  which  are  added  X-b 
and  X-c  to  illustrate  the  thickening  of  the  cerebellar  pia  mater.  The  case  exhibited  a 
somewhat  questionable  focal  mononucleosis  about  the  vessels  of  one  region. 

Microscopic  examination  showed  numerical  hyperplasia  of  cells  in  a  number  of  places. 
The  brain  is  fairly  complex  in  construction,  but  the  corpus  callosum  (X-h  and  X-i)  shows 
a  slight  thinning  in  the  posterior  third. 


I-c  i-d 

CASE   1 —  MICROCEPHALY.     LOW  IDIOT 


Memoirs  American  Academy   of  Arts  and  Sciences.     Vol.  XIV.-  Waverley  Researches. 


I-e,  1-f,  1-g 

CASE  I —  MICROCEPHALY.     LOW  IDIOT 


Memoirs  American  Academy  of  Arts  and  Sciences.     Vol.  XIV.-  Waverley   Researches. 


Il-a 


Il-b 


II-c  Il-d 

CASE   II  — MICROCEPHALY.   ENCEPHALITIC.      LOW   IDIOT 

Memoirs  American  Academy  of  Arts  and  Sciences.     Vol,  XIV.  —  Waverley  Researches. 


o 
5 

o 

-j 

o 
h 
_J 
< 

I 

D_ 
UJ 

O 

LU 


< 

I 


o 
o 

E 

o 


< 
o 


> 

X 


Ill-a 


Ill-b 


III-c  Ill-d 

CASE   III  —  MICROCEPHALY.     IMBECILE  "  LITTLE  ZIP" 


Memoifs  American  Academy  of  Arts  and  Sciences.     Vol.   X  I  V. — Waverley   Researches. 


IV-a 


IV-b 


IV-c 


CASE  IV  — OLD  ALMSHOUSE  MORON 
Memoirs  American  Academy  of  Arts  and  Sciences.    Vol.  XIV. —  Waverley  Researches. 


IV-d 


IV-e 


IV-f 


IV-g 


IV-h 


IV-i  IV-j 

CASE  IV  — ALMSHOUSE  MORON.  NOTE  HYDROCEPHALUS 


Memoirs   American  Academy  of  Arts  and  Sciences.     Vol.  XIV. — Waverley  Researches. 


V-a 


V-b 


V-c  V-d 

CASE  V  — MORON.  TRUANT.   DEMENTIA  PRAECOX   (?) 

Memoirs  American  Academy  of  Arts  and  Sciences.     Vol.  XIV.-  Waverley   Researches. 


V-g  V-h 

CASE  V— MORON.  TRUANT.   DEMENTIA  PRAECOX   (?) 


Memoirs  American  Academy  of  Arts  and  Sciences.     Vol.  XIV. —  Waverley   Researches. 


Vl-b 


VI-c  VI-d 

CASE  VI  —IDIOT  (APHASIA.  VOCAL  CORD  ABSENT).    SYPHILITIC  (?) 
Memoirs  American  Academy  of  Arts  ano  Sciences.    Vol.  X I V.  —  Waverley  Researches. 


Vl-e 


Vl-f 


Vl-g  Vl-h 

CASE  VI  — IDIOT.     SYPHILITICA)   CORPUS  CALLOSUM   THIN 


Memoirs  American  Academy  of  Arts  and  Sciences.     Vol.   XIV. — Waverley   Researches. 


VII-c 

CASE  VII  — IMBECILE.     SYPHILITIC  (??) 

Memoirs  American  Academy  of  Arts  ano  Sciences.     Vol.  XIV.-  Waverley  Researches. 


Vll-d 


Vll-e 


VH-f 


VH-g  VH-h 

CASE  VI  I  — IMBECILE.     SYPHILITIC  (?) 

Memoirs  American  Academy  of  Arts  and  Sciences.    Vol.  XIV.  —  Waverlev  Researches. 


VII  I-a 


VHI-b 


VIII-c  VHI-d 

CASE  VIII  —  MORON  OR  SUBNORMAL.     EXECUTED  MURDERER 


Memoirs   American  Academy  of  Arts  and  Sciences.     Vol.  X  I  V.  -  Waverley  Researches. 


VHI-e 


VHI-f 


VHI-g 


VHI-h  VHI-i 

CASE  VIII  —  MORON  OR  SUBNORMAL.     EXECUTED   MURDERER 


Memoirs  American  Academy  of  Arts  and  Sciences.      Vol.  XIV.-  Waverley  Researches. 


lX-a 


IX-b 


IX-c  IX-d 

CASE  IX  — "ABLE   BODIED"   IMBECILE.     BRAIN  WEIGHT  1622  GRAMS 

Memoirs  American  Academy  of  Arts  and  Sciences.     Vol.  XIV.-  Waverlev  Researches. 


IX-e 


IX-f 


IX-g  IX-h 

CASE  IX  — "ABLE  BODIED"   IMBECILE      BRAIN  WEIGHT  1622  GRAMS 


Memoirs  American  Academy  of  Arts  and  Science?.    Vol.   XIV. — Waverley   Researches. 


IX-] 


IX-j 


IX-k 


IX-1 


CASE  IX  — "ABLE   BODIED"   IMBECILE.     BRAIN  WEIGHT  1622  GRAMS 
Memoirs  American  Academy  of   Arts  and  Sciences.     Vol.  XIV. — Waverley   Researches. 


X-a 


X-b 


X-d  X-e 

CASE  X  — LOW  IMBECILE  (BINET  2.4) 
Memoirs  American  Academy  of  Arts  and  Sciences.     Vol.  XIV. — Waverley   Researches. 


X-c 


X-f 


X-h 


CASE  X  — LOW   IMBECILE   (BINET  2.4) 
Memoirs  Amer.can  Academy  of    Arts  and  Sc.ences.     Vol.  X  I  V-Waverley   Researches. 


X-i 


